Canadian Diabetes Association
Clinical Practice Guidelines
Hypoglycemia
Chapter 14
Dale Clayton, Jean-François Yale, Vincent Woo
Hypoglycemia Checklist
2013

RECOGNIZE hypoglycemia and CONFIRM

DIFFERENTIATE mild-moderate vs. severe

TREAT hypoglycemia but AVOID overtreatment

AVOID hypoglycemia in the future
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Definition of Hypoglycemia
1.
Development of neurogenic or neuroglycopenic symptoms
Neurogenic
(autonomic)
Neuroglycopenic
Trembling
Difficulty Concentrating
Palpitations
Confusion
Sweating
Weakness
Anxiety
Drowsiness
Hunger
Vision Changes
Nausea
Difficulty Speaking
Dizziness
2.
Low blood glucose (<4 mmol/L if on insulin or
secretagogue)
3.
Response to carbohydrate load
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Severity of Hypoglycemia
• Mild
– Autonomic symptoms present
– Individual is able to self-treat
• Moderate
– Autonomic and neuroglycopenic symptoms
– Individual is able to self-treat
• Severe
– Requires the assistance of another person
– Unconsciousness may occur
– Plasma glucose is typically <2.8 mmol/L
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Drug Induced Hypoglycemia
•
Can result in significant morbidity and mortality
•
Serious obstacle to meet glycemic targets
•
Counsel patients who drive on insulin or
secretagogues re: self-monitoring of blood glucose
and taking appropriate precautions
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Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to
relieve symptoms
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and
retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a
snack with 15 g carbohydrate plus protein
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Examples of 15 g Simple Carbohydrate
•
15 g of glucose in the form of glucose
tablets
•
15 mL (3 teaspoons) or 3 packets of sugar
dissolved in water
•
175 mL (3/4 cup) of juice or regular soft
drink
•
6 Lifesavers (1=2.5 g of carbohydrate)
•
15 mL (1 tablespoon) of honey
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Recognize Risk Factors for Severe
Hypoglycemia
Risk factors in Type 1 DM
patients
Risk factors in Type 2 DM
patients
Adolescence
Elderly
Children unable to detect and/or
treat mild hypoglycemia
Poor health literacy, Food
insecurity
A1C <6.0%
Increased A1C
Long duration of diabetes
Duration of insulin therapy
Prior episode of severe
hypoglycemia
Severe cognitive impairment
Hypoglycemia unawareness
Renal impairment
Autonomic neuropathy
Neuropathy
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Treatment of SEVERE Hypoglycemia in
Conscious Person
1. Treat with oral “fast sugar” (simple carbohydrate)
(20 g) to relieve symptoms
2. Retest in 15 minutes to ensure the BG> 4.0
mmol/L and retreat with a further 15 g of
carbohydrate if needed
3. Eat usual snack or meal due at that time of day or
a snack with 15 g carbohydrate plus protein
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Treatment of SEVERE Hypoglycemia in
Unconscious Person with no IV Access
1. Treat with 1 mg of glucagon subcutaneously or
intramuscularly
2. Call 911
3. Discuss with diabetes healthcare team
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Treatment of SEVERE Hypoglycemia in
Unconscious Person with IV Access
1. Treat with 10-25 g (20-50 cc of D50W) of glucose
intravenously over 1-3 minutes
2. Retest in 15 minutes to ensure the BG >4.0 mmol/L
and retreat with a further 15 g of carbohydrate if
needed
3. Once conscious, eat usual snack or meal due at that
time of day or a snack with 15 g carbohydrate plus
protein
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Hypoglycemia and Driving
Safe blood glucose (BG)
prior to driving
•
•
BG ≥ 5.0 mmol/L
If BG <5.0 mmol/L prior to driving:
–
Take 15 g carbohydrate, re-check in 15 minutes
–
If BG was <4.0 mmol/L, wait at least 45 minutes after the BG
≥5.0 mmol/L  safe to drive
–
If BG was 4.0-4.9 mmol/L, safe to drive once BG ≥5.0 mmol/L
Need to re-check BG every 4 hours of continuous
driving and carry simple carbohydrate snacks
Iain S. Begg et al . Canadian Journal of Diabetes. 2003;27(2):128-140.
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Recommendation 1
1. Mild to moderate hypoglycemia should be treated
by oral ingestion of 15 g carbohydrate; glucose or
sucrose tablets/solutions are preferable to orange
juice and glucose gels [Grade B, Level 2]
Patients should retest blood sugar in 15 minutes
and retreat with another 15 g of carbohydrates if BG
remains <4.0 mmol/L [Grade D, Consensus]
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Recommendation 2
2. Severe hypoglycemia in a conscious person
should be treated by oral ingestion of 20 g of
carbohydrate, preferable as glucose tablets or
equivalent.
Blood sugar should be retested in 15 minutes, and
then retreated with a further 15 g of glucose if BG
remains <4.0 mmol/L [Grade D, Consensus]
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Recommendation 3
3. Severe hypoglycemia in an unconscious
individual:
– No IV access: 1 mg of glucagon should be
administered subcutaneously or intramuscularly.
Caregivers or support persons should call for
emergency services and the episode should be
discussed with the diabetes healthcare team as
soon as possible [Grade D, Consensus]
– With IV access: 10-25 g (20-50 cc of D50W) of
glucose should be given intravenously over 1-3
minutes [Grade D, Consensus]
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Recommendation 4
4. For individuals at risk of severe hypoglycemia,
support persons should be taught how to
administer glucagon by injection [Grade D, Consensus]
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Recommendation 5
5. Once the hypoglycemia has been reversed, the
person should have the usual meal or snack that
is due at that time of the day to prevent repeated
hypoglycemia [Grade D, Consensus].
If a meal is > 1 hour away, a snack (including 15 g
of carbohydrate and protein source) should be
consumed [Grade D, Consensus]
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Recommendation 6
2013
6. Patients receiving antihyperglycemic agents that
may cause hypoglycemia should be counseled
about strategies for prevention, recognition and
treatment of hypoglycemia related to driving and
be made aware of provincial driving regulations
[Grade D, consensus]
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CDA Clinical Practice Guidelines
www.guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
www.diabetes.ca – for patients
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association