Hypoglycemia in adults with diabetes: an update on prevention and management

Diabetes Canada is drawing attention to the prevention, recognition and management of hypoglycemia in adults with diabetes. The frequency and severity of hypoglycemia can have a negative impact on quality of life in patients with diabetes. The fear of future episodes of hypoglycemia may lead some individuals to target higher blood glucose levels in an attempt to avoid hypoglycemia, which can worsen overall glycemic management. As a result, preventing, recognizing and treating hypoglycemia is an important part of diabetes management. An updated guidance document from Diabetes Canada outlines the three levels of hypoglycemia, symptoms of hypoglycemia and risk factors for developing severe hypoglycemia. Physical (neurologic, cardiovascular, musculoskeletal) and psychosocial complications of hypoglycemia, including fear of hypoglycemia are also addressed. Prevention of hypoglycemia is safer and more effective than addressing the many short-term and long-term consequences of hypoglycemia. The choice and dose of antihyperglycemic agent and the use of continuous glucose monitoring (CGM) technologies can reduce episodes of hypoglycemia. These are discussed in further detail in the guidance document. Although a target glycated hemoglobin (A1C) of < 7% is recommended for most individuals with diabetes to prevent long-term complications, patients with recurrent and severe hypoglycemia (particularly older adults with frailty treated with insulin or insulin secretagogues) may benefit from individualized A1C targets to reduce the risk of hypoglycemia. Appropriate treatment of hypoglycemia, based on event severity and duration, is crucial to increase glucose levels and relieve symptoms quickly. Overtreatment should be avoided, if possible, as it can result in weight gain or rebound hyperglycemia. Treatment for the various levels of hypoglycemia are discussed in the guidance document. Level 1 and 2 hypoglycemia events are self-treatable with oral glucose. Treatment of level 3 hypoglycemia requires the assistance of another person for recovery. It can be treated with oral glucose if the patient is still able to swallow. When the individual cannot swallow or when oral ingestion is unsafe, patients should be treated with glucagon (subcutaneous, intramuscular or intranasal). Details of these treatments are provided in the guidance document. The guidance document includes a figure that summarizes the management of hypoglycemia in adults with diabetes, categorized into the three main components: education, prevention and treatment. Key messages for healthcare providers are summarized below: Hypoglycemia caused by insulin or insulin secretagogues (sulfonylureas, meglitinides) can cause distressing and potentially debilitating complications. It is imperative that these events are reduced in frequency and severity, recognized quickly and treated safely. Individuals with diabetes who are at high risk for hypoglycemia, and their support persons (friends, family, colleagues), should be identified and counselled about ways to prevent low blood glucose, recognize hypoglycemia and treat hypoglycemia. At each clinic visit, individuals at high risk for hypoglycemia who are treated with insulin or insulin secretagogues should be reassessed for need for these agents and their doses appropriately modified to reduce the risk of hypoglycemia. Hypoglycemia should be detected and treated promptly by using an intervention that provides the fastest rise in blood glucose to a safe level, to reduce the risk of injury, and to relieve symptoms quickly. Once blood glucose reaches a safe level, the individual should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia. If a meal is > 1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumed. Individuals with type 1 diabetes and those with type 2 diabetes treated with insulin or insulin secretagogues should be screened for impaired awareness of hypoglycemia. Fear of hypoglycemia is an underestimated problem. It has negative impacts on mental health and can lead individuals to target higher blood glucose values, overtreat hypoglycemia, and avoid activities and social situations that may result in hypoglycemia. Individuals at high risk for severe hypoglycemia (e.g., those treated with insulin) should be prescribed glucagon, and the patient’s support persons should be provided counselling on administration technique. Continuous glucose monitoring should be used in conjunction with a structured educational program to detect and prevent hypoglycemia for those at high risk of hypoglycemia, impaired awareness of hypoglycemia or fear of hypoglycemia. The updated guidance document also includes 12 recommendations relating to counselling and screening, prevention of hypoglycemia and treatment of hypoglycemia. Reference 1. Lega IC, Yale JF, Chadha A, et al; Diabetes Canada Clinical Practice Guidelines Expert Working Group. Hypoglycemia in adults. Can J Diabetes 2023;47(7):548-59. (accessed November 14, 2023).

Hypoglycemia in adults with diabetes: an update on prevention and management

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