In this article, we’ll provide a quick overview of the treatment and investigations of patients with hypoglycaemia.
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Diabetic: Glucose <4mmol/L usually warrants treatment.
Non-Diabetic: Cut off <2.8mmol/L.
Above this value is usually physiological, but if below 3.5mmol/L with symptoms that improve on correction, an endocrine referral is warranted.
Conscious – 100-150ml of juice or 5-7 tablets of glucose or 4 jelly babies.
Recheck every 10-15 minutes until 4 mmol/L.
Unconscious – 100ml of 20% glucose or 200ml of 10% glucose intravenously
If unable to obtain IV access or difficult to obtain, give Glucagon 1mg IM.
Once the patient has recovered, give them a longer-acting carbohydrate snack such as a biscuit or slice of toast to ensure they don’t develop hypoglycaemia. You might need to give a continuous glucose infusion to a patient with long-acting insulin on board particularly if they have AKI impairing insulin clearance.
- Nurses should be able to give the emergency treatment with a verbal order in an emergency
- Glucagon doesn’t work well in a malnourished/liver disease patient (minimal glycogen stores to release) & can cause significant nausea so do give an antiemetic
- Foods with high-fat content impair sugar release therefore avoid things like chocolate
- Avoid 50% dextrose as this is too viscous & 5% dextrose as this has far too little sugar. 10% or 20% tends to be what is typically used.
- Don’t treat high CBGs post-treatment, it can be corrected with the next meal & also a single episode of hyperglycaemia is rarely dangerous!
Next Steps – Identify the Cause
The most common cause is a patient on diabetes medication with reduced oral intake, alcohol, infection or exercise.
- Starvation (if ketones are raised this can be a clue!)
- Acute liver failure (usually acidotic and high lactate, deranged LFTs)
- Adrenal crisis (check cortisol)
- Rapidly spreading malignancy, usually haematological (raised lactate, history)
- Medications e.g. Quinine, Co-Trimoxazole (Septrin)
- Post-bariatric surgery
- Reactive hypoglycaemia (after a large meal)
- End of life (reconsider whether blood glucose measurement is appropriate)
- (And very, very rarely insulinoma)
How to adjust diabetes medication
- The most common medications to cause hypoglycaemia are insulin & sulphonylureas (i.e. gliclazide)
- Remember that hypoglycaemia is caused by the medication before the event (i.e. early morning hypoglycaemia is caused by the evening medication)
- If the patient is on gliclazide, reducing it by about 40mg is usually enough
- If the hypoglycaemia is due to basal insulin (early morning/before meals) then reduce it by 10-20%. Never omit basal insulin!
- If due to meal-time short-acting insulin, then reduce this by typically 2-4 units
- If you’re unsure how to adjust the diabetes medication, refer to the diabetes specialist nurse
- If the patient is complicated (e.g. on NG/TPN feed) then refer to the diabetes specialist doctor
- If the patient does not have diabetes, have a low threshold to refer to the endocrine registrar.
For non-diabetics, it is helpful to take the following tests prior to correction
- Lab glucose (otherwise we can’t interpret any tests below!)
- Urine sulphonylurea screen
Written by Dr Akash Doshi (Endocrine & Diabetes ST4) & Dr Tom Crabtree (Endocrine SpR)
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