Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.

Signs & Symps

• Autonomic: Sweating, Palpitations, Shaking, Hunger
• Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
• General: Nausea, Headache

Risk Factors

• Medical: 
  • Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
  • Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
  • GIT: Gastroenteritis, impaired absorption, Bariatric surgery
  • Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
  • Sepsis
  • Terminal illness
• Lifestyle:
  • Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
  • Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
  • Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol

Treatment

Conscious & Orientated

1. 15-20g fast acting glucose
   • 4-5 jelly babies
   • 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
   • 150-200ml fresh fruit juice
2. Rpt Blood Glucose 10-15min
   • if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
3. Blood Glucose remains <4.0mmol/l
   • 150-200ml 10% Glucose IV
   • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
4. Blood Glucose >4.0mmol/l – Give long acting Carbs
   • 2 Biscuits
   • 1 Slice bread/toast
   • 200-300ml milk (not soya)
   • Meal
5. Don’t omit insulin injections
6. Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
7. Patient Advice Sheet

Conscious but agitated, confused, unable to cooperate

• If patient CAN cooperate – follow guide above
• If patient CAN’T cooperate
  • 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
  • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
  • Follow subsequent steps as above

Unconscious, seizures, very aggressive

Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.

Although you will need to follow the remaining steps the patient will almost certainly require admission.

Reference

Patient Advice Sheet – Hypo’s

Joint British Diabetic Society – The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition