Managing an acute episode of hypoglycaemia (CKS)

Hypoglycaemia (a blood glucose level less than 3.5 mmol/L) is an inevitable adverse effect of insulin therapy. The absolute blood glucose level at which signs and symptoms begin to occur can vary between people.

Hypoglycaemia should be treated as soon as it is recognised, either by symptoms or by a blood glucose test. If the blood glucose is >4 mmol/l with symptoms, then a small snack may be taken, e.g. an apple, a small banana, a biscuit. If it is not possible to test, often the person's experience tells them they do not have sufficient time to test, then treatment should be given immediately.

If the person is able to swallow:

• Children and young people should be given approximately 0.3 g/kg of a fast-acting carbohydrate.
• Adults should promptly consume 10–20 g of a fast-acting carbohydrate, preferably in liquid form.
• Examples include:
  • 5 glucose tablets; 6 dextrose tablets;
  • 200 mL (small carton) of fresh fruit juice (not sugar-free or reduced-sugar);
  • 3–4 heaped teaspoonfuls of sugar added to a cup of water;
  • 4 large jelly babies or 7 large jelly beans; 
  • 2 tubes of glucose 40% gel
• Note: advise to avoid chocolates and biscuits as they have a lower sugar content, and their high fat content may delay stomach emptying.
• Advise to recheck blood glucose levels after 10–15 minutes.
  • Hypoglycaemia should be reversed in about 10 minutes.
  • Improvements in clinical signs and symptoms may lag behind improvement in blood glucose level. 
• If there is no response or an inadequate response, repeat oral intake as above, and re-test blood glucose levels after another 15 minutes.
• When symptoms improve or normal blood glucose is restored, advise on the need for longer-acting carbohydrate to maintain blood glucose levels and prevent recurrence of hypoglycaemia. 
  • If the next meal is due, it should contain carbohydrate such as bread, potatoes, or pasta.
  • If the next meal is not due soon, the person should consume a carbohydrate-containing snack such as a sandwich, two plain biscuits, or a banana.
• The Diabetes UK patient resource Having a hypo may be useful. 

If the person is unable to swallow or is unconscious:

• IM glucagon should be administered immediately
  • For children younger than 8 years of age (or body weight less than 25 kg), 500 micrograms of glucagon should be given.
  • For all other people, 1 mg of glucagon should be given.

• If the person does not respond to glucagon treatment within 10 minutes, emergency 999 transfer to hospital should be arranged for treatment with IV glucose
• If the person responds to glucagon treatment within 10 minutes and is sufficiently alert and able to swallow safely, advise them to eat some oral carbohydrate (to replace the body's supply and to prevent relapse of hypoglycaemia)