2. OBJECTIVESOBJECTIVES
At the end of this topic, the participantsAt the end of this topic, the participants
will be able to:will be able to:
To understand what term hypoglycemiaTo understand what term hypoglycemia
meansmeans
To list the common symptoms ofTo list the common symptoms of
hypoglycemiahypoglycemia
To describe the common causes ofTo describe the common causes of
hypoglycemiahypoglycemia
To understand how to prevent &To understand how to prevent &
effectively self manage hypoglycemiaeffectively self manage hypoglycemia
reaction.reaction.
3. HYPOGLYCEMIAHYPOGLYCEMIA
DEFINITIONDEFINITION
defined as the development of autonomicdefined as the development of autonomic
and neuroglycopenic symptoms, a lowand neuroglycopenic symptoms, a low
blood glucose level (<4.0 mmol/L forblood glucose level (<4.0 mmol/L for
people treated with insulin or insulinpeople treated with insulin or insulin
secretagogue), and symptomssecretagogue), and symptoms
responding to the administration ofresponding to the administration of
carbohydrates.carbohydrates.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
4. HYPOGLYCEMIAHYPOGLYCEMIA
UNAWARENESSUNAWARENESS
Is the term given when people do notIs the term given when people do not
experience the first stage symptoms andexperience the first stage symptoms and
are unaware that their blood glucose areare unaware that their blood glucose are
low. Possible reasons for this includelow. Possible reasons for this include
frequent low or untreated blood sugarfrequent low or untreated blood sugar
levels, long standing diabetes and nervelevels, long standing diabetes and nerve
damage.damage.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
5. CAUSES OFCAUSES OF
HYPOGLYCEMIAHYPOGLYCEMIA
Side effects of diabetes medicationsSide effects of diabetes medications 1,21,2
Less intake of foodLess intake of food
Increased in physical activityIncreased in physical activity
Excessive alcohol intakeExcessive alcohol intake
Food malabsorption (celiac disease)Food malabsorption (celiac disease)
1. O’Shaughnessey C, H. Hypoglycemia. Primary Care Reports Available from: CINAHL Plus with Full Text.
2. Sutton L, Chapman-Novakofski K. Hypoglycemia education needsAvailable from: MEDLINE.
3. Holt P. Effective management of hypoglycaemia in diabetes. Available from: CINAHL Plus with Full Text.
6. CAUSES OFCAUSES OF
HYPOGLYCEMIAHYPOGLYCEMIA
Poor injection techniquePoor injection technique
Insulin prescription & administrationInsulin prescription & administration
errorserrors
Mistiming of prescribed medication inMistiming of prescribed medication in
relation to food consumption.relation to food consumption.
Holt P. Effective management of hypoglycaemia in diabetes. Available from: CINAHL Plus with Full Text.
7. SEVERITY OFSEVERITY OF
HYPOGLYCEMIAHYPOGLYCEMIA
MILD – autonomic symptoms are present.MILD – autonomic symptoms are present.
The individual is able to self-treat.The individual is able to self-treat.
MODERATE – autonomic &MODERATE – autonomic &
neuroglycopenic symptoms are present.neuroglycopenic symptoms are present.
The individual is able to self-treat.The individual is able to self-treat.
SEVERE – individual requires assistanceSEVERE – individual requires assistance
of another person. Unconsciousness mayof another person. Unconsciousness may
occur.occur.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
9. TREATMENT OFTREATMENT OF
HYPOGLYCEMIAHYPOGLYCEMIA
GOALS:GOALS: To detect and treat a low bloodTo detect and treat a low blood
glucose level promptly by using an interventionglucose level promptly by using an intervention
that provide a rapid rise in blood glucose to athat provide a rapid rise in blood glucose to a
safe level, eliminating the risk for injury, andsafe level, eliminating the risk for injury, and
relieving symptoms quickly.relieving symptoms quickly.
15 g of glucose will usually increase blood15 g of glucose will usually increase blood
glucose by 2.1 mmol/L within 20 minutes withglucose by 2.1 mmol/L within 20 minutes with
adequate symptom relief for most people.adequate symptom relief for most people.
20 g of glucose will usually increase blood20 g of glucose will usually increase blood
glucose by 3.6 mmol/L within 45 minutes.glucose by 3.6 mmol/L within 45 minutes.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
10. TREATMENT OFTREATMENT OF
HYPOGLYCEMIAHYPOGLYCEMIA
MILD TO MODERATE HYPOGLYCEMIAMILD TO MODERATE HYPOGLYCEMIA
15 g of oral carbohydrates, preferably as glucose or15 g of oral carbohydrates, preferably as glucose or
sucrose tablets or solution. Retest blood glucose in 15sucrose tablets or solution. Retest blood glucose in 15
minutes; repeat treatment if BG still <4.0 mmol/L.minutes; repeat treatment if BG still <4.0 mmol/L.
SEVERE HYPOGLYCEMIA (CONSCIOUS)SEVERE HYPOGLYCEMIA (CONSCIOUS)
20 g of oral carbohydrates (glucose tablets or20 g of oral carbohydrates (glucose tablets or
equivalent); retest in 15 minutes & repeat treatment ifequivalent); retest in 15 minutes & repeat treatment if
BG still <4.0 mmol/LBG still <4.0 mmol/L
SEVERE HYPOGLYCEMIA (UNCONSCIOUS)SEVERE HYPOGLYCEMIA (UNCONSCIOUS)
1 mg of GLUCAGON subcutaneously or1 mg of GLUCAGON subcutaneously or
intramascularly or 10 to 25 g of glucoseintramascularly or 10 to 25 g of glucose
intraveneously (20 – 50 cc of D50W)intraveneously (20 – 50 cc of D50W)
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
11. TREATMENT OFTREATMENT OF
HYPOGLYCEMIAHYPOGLYCEMIA
Examples of 15 g of carbohydrates:Examples of 15 g of carbohydrates:
4 glucose tablets4 glucose tablets
15 mL (3 teaspoons) or 3 packets of table sugar15 mL (3 teaspoons) or 3 packets of table sugar
dissolved in waterdissolved in water
175 mL (3/4 cup) of juice or regular drink175 mL (3/4 cup) of juice or regular drink
15 mL (1 teaspoon) of honey15 mL (1 teaspoon) of honey
• To prevent repeated hypoglycemia, once theTo prevent repeated hypoglycemia, once the
hypoglycemia has been reversed, the person shouldhypoglycemia has been reversed, the person should
have the usual meal or snack that is due at that timehave the usual meal or snack that is due at that time
of the day. If a meal is >1 hour away, a snackof the day. If a meal is >1 hour away, a snack
(including 15 g CHO & a protein source) should be(including 15 g CHO & a protein source) should be
consumed.consumed.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
12. PREVENTION OFPREVENTION OF
HYPOGLYCEMIAHYPOGLYCEMIA
Eat regular meals, have enough at eachEat regular meals, have enough at each
meal, and try not to skip meals ormeal, and try not to skip meals or
snacks.snacks.
Check blood sugar before sports,Check blood sugar before sports,
exercise, or other physical activity andexercise, or other physical activity and
have a snack if the level is lower thanhave a snack if the level is lower than
expected.expected.
Lowth M. Hypoglycaemia Prevention and management. 2012. Available from: Consumer Health Complete -
EBSCOhost.
13. PREVENTION OFPREVENTION OF
HYPOGLYCEMIAHYPOGLYCEMIA
Adjusting medication before physicalAdjusting medication before physical
activity.activity.
Check blood glucose periodically afterCheck blood glucose periodically after
physical activity.physical activity.
Alcoholic beverages should always beAlcoholic beverages should always be
consumed with a snack or meal at theconsumed with a snack or meal at the
same time.same time.
Lowth M. Hypoglycaemia Prevention and management. 2012. Available from: Consumer Health Complete -
EBSCOhost.
14. PREVENTION OFPREVENTION OF
HYPOGLYCEMIAHYPOGLYCEMIA
Check blood sugar level before driving andCheck blood sugar level before driving and
at least every 4 hours (more often in casesat least every 4 hours (more often in cases
of hypoglycemia unawareness) during longof hypoglycemia unawareness) during long
drives.drives.
Drivers should not drive when blood sugarDrivers should not drive when blood sugar
level is below 4.0 mmol/L, and should notlevel is below 4.0 mmol/L, and should not
begin to drive without prophylacticbegin to drive without prophylactic
carbohydrate treatment.carbohydrate treatment.
Drivers should stop and treat themselves asDrivers should stop and treat themselves as
soon as hypoglycemia is suspected.soon as hypoglycemia is suspected.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
15. PREVENTION OFPREVENTION OF
HYPOGLYCEMIAHYPOGLYCEMIA
Drivers should not drive until 45 to 60Drivers should not drive until 45 to 60
minutes after the effective treatment ofminutes after the effective treatment of
mild to moderate hypoglycemia.mild to moderate hypoglycemia.
Always carry blood glucose monitoringAlways carry blood glucose monitoring
equipment and supplies of rapidlyequipment and supplies of rapidly
absorbable carbohydrates within easyabsorbable carbohydrates within easy
reach when driving.reach when driving.
2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
16. RECOMMENDATIONRECOMMENDATION
An immediate source of glucose orAn immediate source of glucose or
sucrose must be always available.sucrose must be always available.
Equipment for blood glucose monitoringEquipment for blood glucose monitoring
must be available for immediatemust be available for immediate
confirmation and safe management ofconfirmation and safe management of
hypoglycemia.hypoglycemia.
Lowth M. Hypoglycaemia Prevention and management. 2012. Available from: Consumer Health Complete -
EBSCOhost.
17. RECOMMENDATIONRECOMMENDATION
Glucagon should readily be accessible,Glucagon should readily be accessible,
especially when there is a high risk ofespecially when there is a high risk of
severe hypoglycemia. Education onsevere hypoglycemia. Education on
administration is essential.administration is essential.
Wear some form of identification orWear some form of identification or
warning of their diabetes.warning of their diabetes.
Lowth M. Hypoglycaemia Prevention and management. Available from: Consumer Health Complete -
EBSCOhost.
Editor's Notes
Hypoglycemia is an emergency situation that can happen suddenly. It is one of the most worrying short-term complications of diabetes expressed by patient with diabetes and is the biggest barrier to meeting target blood glucose goals. It can be extremely frightening, incapacitating and life threatening and seriously affect cognitive functioning. As a result, many people with diabetes prefer to have a higher than normal blood glucose levels to avoid hypoglycemia but in doing so increases the risk of developing serious, debilitating long-term complications of diabetes.
Defined by triad of typical signs and symptoms of hypoglycemia; documented low blood glucose level, and correction of signs and symptoms with normalization of glucose levels thru the administration of rapid acting carbohydrates.
The main underlying cause of hypoglycemia is too much circulating insulin for the body’s requirement either by exogenous (injection) or endogenous, secreted by the pancreas. Not eating enough carbohydrate (carb) at a meal to match the amount of insulin available in the blood. Taking the medication as prescribed, but skipping or delaying a meal, usually unintentionally. This may be a problem for people with an active lifestyle, who cannot easily eat the same amount of food at the same time each day. Taking more medication than needed to match the carb eaten in the meal. This may occur during periods of weight loss when insulin resistance has been reduced and less insulin will be required for the amount of carb consumed.
Evidence suggests that 15 g of glucose (monosaccharide) is required to produce an increase in BG of approximately 2.1 mmol/L within 20 minutes, with adequate symptom relief for most people. A 20-g oral glucose dose will produce a BG increment of approximately 3.6 mmol/L at 45 minutes . Other choices such as milk and orange juice are slower to increase BG levels and provide symptom relief.
The treatment of hypoglycemia varies based on its severity, cause, and location of treatment.
Teaching individuals with diabetes about the prevention and management of hypoglycemia will prevent related complications (intellectual impairment, unconsciousness, seizures, death) and enhances self-care behaviors such as adherence to healthy diet, frequent blood glucose monitoring, exercise, and medication adherence.
