Hypoglycaemia or low blood glucose is a condition in which the level of glucose (sugar) in the blood drops below 2.5 mmol/L or 45 mg/dl. The condition manifests itself by a number of symptoms that usually disappear 10 to 15 minutes after consuming sugars.
Medications:
Mild Hypoglycaemia
- Powder Glucon D 1 tablespoon (15 gms) stat.
- If patient is able to swallow, then give 15 – 20 g of quick-acting carbohydrate. Avoid fruit juice in renal failure.
- If blood glucose level is less than 75mg/dl after 10 – 15 minutes, then repeat above treatment options up to 3 times.
- If patient is still hypoglycaemic consider i.v. glucose (as per severe hypoglycaemia section below) or inj. Glugon 1mg (Glucagon 1 mg) i.m. once only.
Once blood glucose level is more than 75 mg/dl, give 20 g of long-acting carbohydrate (two biscuits/slice of bread/200 – 300 ml milk) or meal containing carbohydrates. Give 40 g of long-acting carbohydrate if i.m. Glucagon has been used.
Regarding glucagon
- It may take up to 15 minutes to work.
- It may be ineffective in undernourished patients, in severe liver disease or in repeated hypoglycaemia.
- Do not use in hypoglycaemia induced by oral hypoglycaemic agents.
- Patients may experience abdominal discomfort and vomiting after glucagon administration.
Moderate Hypoglycaemia
- If patient is agitated/non-cooperative but can swallow, give Glucose Gel 1.5 – 2 tubes squeezed between teeth and gums.
- If blood glucose level is less than 75 mg/dl after 10 – 15 minutes, then repeat above treatment options up to 3 times.
- If patient is still hypoglycaemic consider i.v. glucose (as per severe hypoglycaemia section below) or inj. Glugon 1mg (Glucagon 1 mg) i.m. once only.
Severe Hypoglycaemia (patient unconscious / fitting or very aggressive)
- Check A (airway), B (breathing), C (circulation) and stop insulin.
- Hospitalise and give i.v. Glucose 20% (100 ml) or 10% (200 ml).
- Inj. Glugon 1mg (Glucagon 1 mg) i.m. once only.
- Re-check glucose after 10 minutes and if blood glucose still less than 75 mg/dl, repeat i.v. glucose as above.
- Once glucose levels are more than 75 mg/dl and if safe – give 20 g of long-acting carbohydrate. Give 40 g of long-acting carbohydrate if i.m. Glucagon has been used.
- If NBM (nil by mouth) – once glucose more than 75 mg/dl – give glucose 10% infusion at a rate of 100 ml/hour. Use intravenous fluids cautiously In patients with renal / cardiac disease and avoid fruit juice in renal failure.
- Keep the patient hospitalised until hypoglycaemic agent has been sufficiently cleared to prevent further hypoglycaemia.
Drug induced hypoglycaemia
- Glycomet (Metformin) and Lantus (Insulin Glargine) are unlikely to cause hypoglycaemia.
- Short-acting insulin (e.g. Humalog/Lispro, Novolog/Aspart) needs short duration of observation after correction (because the insulin action continues for upto 6 hours).
- Sulfonylureas causes prolonged insulin release therefore to observe for 24 hours.
- Levemir (insulin Detemir) starts acting at 1-2 hours and peaks at 6-8 hours, hence observe for 12 to 24 hours and check glucose every 1-2 hours.
- Insulin pump induced hypoglycaemia needs discontinuation of the pump and checking the pump for malfunction.
General advice:
- Educate patient about symptoms of hypoglycaemia
- Advice preventative measures such as immediate glucose supplements
- Dietary advice for patients with diabetes
Investigations :
Investigations are indicated for repeated/prolonged hypoglycaemia.
- Renal function tests – to rule out renal impairment
- Fasting serum C-Peptide and insulin levels – to rule out insulinoma for patients with repeated hypoglycaemia
- Serum cortisol – to rule out adrenal insufficiency
- Urine catecholamines – to rule out pheochromocytoma
- Thyroid function tests – to rule out hyperthyroidism
- CT abdomen – to rule out pancreatic tumour
- Liver function tests – to rule out liver dysfunction
- USG abdomen – to rule out liver cirrhosis
Referral:
Consider further referral to diabetologist in case of repeated hypoglycaemia or if patient presents with complications.