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Hypoglycemia

Key sources
The following summarized guidelines for the evaluation and management of hypoglycemia are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024; 2023), the Endocrine Society (ES 2022; 2016; 2013; 2009), the American Heart Association (AHA/ASA 2022; 2019), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2020; 2013), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the Dumping Syndrome Consensus Group (DS-CG 2020), the United Kingdom Kidney Association (UKKA 2020), the Japanese Society of Nephrology (JSN 2019), the Diabetes Canada (DC 2018), the European Association for the Study of Obesity (EASO 2017), the American Society for Metabolic and Bariatric Surgery (ASMBS 2017), the Pediatric Endocrine Society (PES 2015), the The Scottish Intercollegiate Guidelines Network (SIGN 2015), and the Guidelines and Audit Implementation Network (GAIN 2014).
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Guidelines

1.Diagnostic investigations

Initial evaluation, patients with diabetes, ADA: assess for a history of hypoglycemia at every clinical encounter in all patients at risk for hypoglycemia and evaluate as indicated.
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  • Initial evaluation (patients without diabetes)

  • Screening for anxiety

  • Screening for cognitive impairment

2.Medical management

Oral carbohydrates
As per ADA 2024 guidelines:
Administer glucose as the preferred treatment of conscious patients with glucose < 70 mg/dL (< 3.9 mmol/L), although any form of glucose-containing carbohydrate may be used. Repeat the treatment if hypoglycemia persists 15 minutes after initial administration.
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Avoid using carbohydrate sources high in protein for the treatment or prevention of hypoglycemia in patients with T2DM, as ingested protein appears to increase insulin response without increasing plasma glucose concentrations.
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  • IV carbohydrates and glucagon

3.Specific circumstances

Neonatal patients: consider evaluating neonates suspected to be at high risk of having a persistent hypoglycemia disorder when the infant is ≥ 48 hours of age so that the period of transitional glucose regulation has passed and persistent hypoglycemia may be excluded before discharge home.
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  • Pediatric patients (evaluation)

  • Pediatric patients (glycemic targets, T1DM)

  • Pediatric patients (glycemic targets, T2DM)

  • Pediatric patients (glucose monitoring, T1DM)

  • Pediatric patients (glucose monitoring, T2DM)

  • Pregnant patients

  • Elderly patients

  • Patients with CKD (glycemic targets)

  • Patients with CKD (considerations for pharmacotherapy)

  • Patients with CKD (continuous glucose monitoring)

  • Patients with CKD (elderly patients)

  • Patients with post-bariatric hypoglycemia (general principles)

  • Patients with post-bariatric hypoglycemia (postprandial hyperinsulinemic hypoglycemia)

  • Patients with post-bariatric hypoglycemia (late dumping syndrome)

  • Patients with acute stroke

  • Patients with hyperkalemia

  • Patients with status epilepticus

4.Preventative measures

General principles: as per ADA 2023 guidelines, assess the hypoglycemia risk, in addition to the assessments of overall health status, diabetes complications, and cardiovascular risk, to guide the ongoing management of diabetes.
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take the hypoglycemia risk into account to guide the choice of pharmacologic agents in patients with T2DM.
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  • Choice of insulin

  • Continuous glucose monitoring

  • Counseling on alcohol use

5.Follow-up and surveillance

Post-hypoglycemia care: as per DC 2018 guidelines, advise patients to have the usual meal or snack that is due at that time of the day, once the hypoglycemia has been reversed, to prevent repeated hypoglycemia. Advise having a snack (including 15 g carbohydrate and a protein source) if a meal is > 1 hour away.
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