Management of Hypoglycemia
Blood glucose testing is one of the tools used by patients with diabetes to help them maintain glycemic control. While it doesn't affect their blood glucose directly, it provides a pinpoint measure of their current blood glucose. This information can then be correlated to a patient's current status to help them gain familiarity with the symptoms of hypo- and hyperglycemia. Self-monitoring of blood glucose (SMBG) also provides positive or negative feedback to a patient, which they can use to evaluate whether their blood glucose is well controlled or not.
The most immediate risk posed to a patient using medications to lower their blood sugar, known as antihyperglycemics, is hypoglycemia or low blood glucose. Blood glucose is measured in units of mmol/L on a practical scale of about 0.5 to 33 mmol/L. Any measurement below 4.0 mmol/L is considered to be hypoglycemia by current standards. The optimal level of control according to current guidelines is 4.0-7.0 mmol/L before meals (fasting or pre-prandial), or 5.0-10.0 at 2 hours after a meal (post-prandial).
There are many commonly observed signs and symptoms of hypoglycemia and they are summarized below. It is important to note, however, that a hypoglycemic state, and its associated symptoms, are relative to a patients average blood glucose. If a patient has uncontrolled blood glucose (consistently above 10.0 mmol/L) for an extended period of time he or she may experience symptoms of hypoglycemia at blood glucose levels higher than 4.0 mmol/L, which is considered the normal range for people with optimal glycemic control. For this reason, it is important to develop patient specific blood glucose targets and attempt to lower a chronically high blood glucose slowly so that the patient's body can become accustomed to the lower level of blood glucose.
Before following these recommendations please read the disclaimer.
The most immediate risk posed to a patient using medications to lower their blood sugar, known as antihyperglycemics, is hypoglycemia or low blood glucose. Blood glucose is measured in units of mmol/L on a practical scale of about 0.5 to 33 mmol/L. Any measurement below 4.0 mmol/L is considered to be hypoglycemia by current standards. The optimal level of control according to current guidelines is 4.0-7.0 mmol/L before meals (fasting or pre-prandial), or 5.0-10.0 at 2 hours after a meal (post-prandial).
There are many commonly observed signs and symptoms of hypoglycemia and they are summarized below. It is important to note, however, that a hypoglycemic state, and its associated symptoms, are relative to a patients average blood glucose. If a patient has uncontrolled blood glucose (consistently above 10.0 mmol/L) for an extended period of time he or she may experience symptoms of hypoglycemia at blood glucose levels higher than 4.0 mmol/L, which is considered the normal range for people with optimal glycemic control. For this reason, it is important to develop patient specific blood glucose targets and attempt to lower a chronically high blood glucose slowly so that the patient's body can become accustomed to the lower level of blood glucose.
Before following these recommendations please read the disclaimer.
Know The Signs & Symptoms
Early Signs & Symptoms (Autonomic or Neurogenic)*
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Late Signs & Symptoms (Neuroglycopenic)*
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*Remember, these signs and symptoms may be seen in patients in the normal range if their body is used to higher blood glucose levels
Hypoglycemia Self Management Protocol
While the goal of diabetes management or glycemic control is to keep blood glucose from being too high, in situations of hypoglycemia it is better to focus on getting the blood glucose level out of the hypoglycemic range than worrying about causing hyperglycemia. In an acute situation hypoglycemia is much more dangerous than moderate hyperglycemia.
This guide focuses on self-management of mild and moderate hypoglycemia. For management of severe hypoglycemia and hypoglycemia in patients who are found unconscious please refer to the Canadian Diabetes Association Guidelines.
This guide focuses on self-management of mild and moderate hypoglycemia. For management of severe hypoglycemia and hypoglycemia in patients who are found unconscious please refer to the Canadian Diabetes Association Guidelines.
Step 1 - Identification of Hypoglycemia (done in one of two ways)
1) Testing blood glucose and seeing a result of 3.9 mmol/L or lower, OR
2) Experiencing signs or symptoms of hypoglycemia (listed above)
1) Testing blood glucose and seeing a result of 3.9 mmol/L or lower, OR
2) Experiencing signs or symptoms of hypoglycemia (listed above)
- In this case test blood glucose right away to confirm hypoglycemia (blood glucose of 3.9 or lower)
- If testing cannot be performed it is safer to treat symptoms first then attempt to test blood glucose
Step 2 - Eat Approximately 15 g of Carbohydrates (as glucose or sucrose)
Potential Sources of 15 g* of carbohydrates:
*If blood glucose is very low (less than 3 mmol/L) or symptoms are severe eat 20 g of carbohydrates instead of 15 g
Potential Sources of 15 g* of carbohydrates:
- 4 glucose tablets (eg. Dex-4 = 16 g glucose)
- 3 tsp or 3 packets of table sugar dissolved in water
- 3/4 cup or 175 mL of non-sugar free juice or non-diet soft drink
- 6 Life Savers
- 15 mL of honey
*If blood glucose is very low (less than 3 mmol/L) or symptoms are severe eat 20 g of carbohydrates instead of 15 g
Step 3 - Wait 15 Minutes, Remain Calm, & Retest Blood Glucose
Despite feelings of anxiety and potential symptoms remain calm while testing blood glucose in order to ensure you get an accurate test.
Despite feelings of anxiety and potential symptoms remain calm while testing blood glucose in order to ensure you get an accurate test.
- If retested blood glucose is above 4.0 mmol/L proceed to Step 4
- If retested blood glucose is 3.9 or below return to Step 2 and repeat ingestion of 15 g carbohydrate
Step 4A - Your Next Meal is Within 1 Hour - You Are Finished
Congratulations! You have successfully managed your hypoglycemic event. It is important that you work with your team of healthcare professionals to develop strategies to prevent these events. The more frequently you experience hypoglycemia the more your body gets used to it. This is dangerous because if your body gets used to hypoglycemia then you may not feel the signs and symptoms of hypoglycemia until they are severe.
- Eat your next meal at your regular time
- Alert your healthcare professional of your hypoglycemic episode at your next appointment and work with them to determine the cause of the hypoglycemic event in order to prevent more episodes in the future
- Eat a more substantial snack including about 15 g of carbohydrate plus a protein source
- Potential Snacks: crackers and cheese or 1/2 sandwich are commonly recommended - You Are Finished
- Eat your next meal at your regular time
Congratulations! You have successfully managed your hypoglycemic event. It is important that you work with your team of healthcare professionals to develop strategies to prevent these events. The more frequently you experience hypoglycemia the more your body gets used to it. This is dangerous because if your body gets used to hypoglycemia then you may not feel the signs and symptoms of hypoglycemia until they are severe.
Strategies to Avoid or Prevent Hypoglycemia
- Carry a sugar source at all times - see recommended list above under Step 2
- Be familiar with the signs and symptoms of hypoglycemia - use your blood glucose meter to test your blood glucose when you feel like your blood glucose may be low and remember what that rest result felt like
- Develop and follow meal, medication, and exercise routines - these 3 factors can affect your blood glucose - if they are consistently maintained you are less likely to experience hypoglycemia
- Understand which of your medications can cause hypoglycemia and be particularly careful to follow your dosing instructions
- Monitor your blood glucose more closely when you are sick, have exercised more than usual, or when ANY of your medications have been changed
- Treat hypoglycemia seriously! - consult your diabetes care team if you have an episode of hypoglycemia, especially the first time
- Discuss changes to your medication therapy with your doctor or pharmacist if you regularly experience hypoglycemia
- Keep documentation of your medical conditions with you at all times - if you are found unconscious your caregivers will be able to determine that you have diabetes and will check for and treat hypoglycemia
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32(suppl 1): S1-S201. Available at: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf