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2018 Clinical Practice Guidelines
C IA
E R
M M
C O
Hypoglycemia F OR
O T
Chapter 14
N
Jean-François Yale MD FRCPC
Breay Paty MD FRCPC
Peter Senior MD FRCPC
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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

2018
Key Changes
• Reinforcement of the importance of counselling
E
U S
individuals on insulin or insulin secretagogues
L
IA
Cthe risk,
and their support persons on R
E
M treatment of
prevention, recognitionMand
hypoglycemia C O
OR
TF
• New information
O
N
• on strategies to reduce the risk of hypoglycemia

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Hypoglycemia Checklist
 RECOGNIZE hypoglycemia and CONFIRM
SE
L U
IA severe
 DIFFERENTIATE mild-moderateCvs.
E R
M M
O AVOID OVERTREAMENT
 TREAT hypoglycemiaCbut
OR
T F
NO
 AVOID hypoglycemia in the future

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Definition of Hypoglycemia
1. Development of neurogenic or neuroglycopenic
symptoms
S E
Neurogenic (autonomic)
L U
Neuroglycopenic
Trembling C IA
Difficulty Concentrating
E R
Palpitations
M M Confusion

CO
Sweating Weakness
Anxiety
OR Drowsiness
T F
N O
Hunger
Nausea
Vision Changes
Difficulty Speaking

2. Low blood glucose (<4 mmol/L if on insulin or

Dizziness

secretagogue)
3. Response to carbohydrate load

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Severity of Hypoglycemia
• Mild
– Autonomic symptoms present SE
– Individual is able to self-treat AL U
I C
• Moderate E R
– Autonomic and neuroglycopenic
O MM
symptoms
R
– Individual is able Cto self-treat
F O
• Severe O T
N
– – Requires the assistance of another person
– Unconsciousness may occur
– Plasma glucose is typically <2.8 mmol/L

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Risk factors for severe hypoglycemia in people treated with

sulfonylureas or insulin

•Prior episode of severe hypoglycemia

•Current low A1C (<6.0%)
•Hypoglycemia unawareness SE
•Long duration of insulin therapy L U
•Autonomic neuropathy C IA
•Chronic kidney disease E R
•Low health literacy O MM
•Low economic status, food insecurity

R C
•Preschool-age children unable to detect and/or treat mild
F O
hypoglycemia on their own
O
•Adolescence T
•PregnancyN
•Elderly
•Cognitive impairment

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Drug Induced Hypoglycemia

E significant
• Can result in
S
L U and mortality
morbidity
IA
R C
E
MM
O • Serious obstacle to meet
R C
F O glycemic targets
O T
N
• Counsel patients who
drive on insulin or
secretagogues re: SMBG
and taking appropriate
SMBG, self-monitoring of blood glucose
precautions NOT FOR COMMERCIAL USE
2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Steps to Address Hypoglycemia

1. Recognize autonomic or neuroglycopenic symptoms

S E
2. L U
Confirm if possible (blood glucose <4.0 mmol/L)
C IA
E R
3. Treat with “fast sugar” (simpleM M
carbohydrate) (15 g) to relieve
symptoms C O
O R
T F
4. NO to ensure the BG >4.0 mmol/L and retreat
Retest in 15 minutes
(see above) if needed

5. Eat usual snack or meal due at that time of day or a snack with
15 g carbohydrate plus protein

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Examples of 15 g Simple
Carbohydrate
• 15 g of glucose in the form of glucose
SE
tablets
L U
C IA
MER
• 15 mL (3 teaspoons) or 3 packets of
M
sugar dissolved in water
O
R C
F
• 150 mL of juiceOor regular soft drink
O T
N (1 = 2.5 g of carbohydrate)
• 6 Lifesavers
• 15 mL (1 tablespoon) of honey

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Treatment of SEVERE Hypoglycemia in

Unconscious Person with no IV Access
1. Treat with 1 mg of glucagon subcutaneously
E or
intramuscularlyL US
C IA
E R
O MM
C
R2. Call 911
F O
O T
N

3. Discuss with diabetes health-care team

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Treatment of SEVERE Hypoglycemia in

Unconscious Person with IV Access
1. Treat with 10-25 g (20-50 mL of D50W) of glucose
intravenously over 1-3 minutes SE
U L
C IA
E R
2. Retest in 15 minutes to
M M
ensure the BG >4.0
O a further 15 g of
mmol/L and retreatCwith
OR
carbohydrate ifFneeded
O T
N
3. Once conscious, eat usual snack or meal due at
that time of day or a snack with 15 g carbohydrate
plus protein

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Treatment of SEVERE Hypoglycemia in

Conscious Person
1. Treat with oral “fast sugar” (simple carbohydrate)
E
S
(20 g) to relieve symptoms LU IA
R C
ME
2. Retest in 15 minutes to
O M ensure the BG> 4.0 mmol/L
and retreat with Ra C
further 15 g of carbohydrate if
needed F O
O T
N
3. Eat usual snack or meal due at that time of day or
a snack with 15 g carbohydrate plus protein

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

2018
Recommendations 1-2
1. All people with diabetes currently using or starting
therapy with insulin or insulin secretagogues and
SE
their support persons should be counselled about the
L U
risk, prevention, recognition andIA
treatment of
C
R severe hypoglycemia
hypoglycemia. Risk factors E for
should be identified andM M
C O addressed [Grade D, Consensus]
OR
F
2. The DHC teamT should review the person with
NO
diabetes’ experience with hypoglycemia at each
visit including an estimate of cause, frequency,
symptoms, recognition, severity and treatment, as
well as the risk of driving with hypoglycemia [Grade D,
Consensus]

DHC, diabetes health-care team

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Recommendation 3 2018

3. In people with diabetes at increased risk of hypoglycemia, the

following strategies may be used to reduce the risk of
hypoglycemia:
• Avoidance of  pharmacotherapies associated with increased
S E
L U
risk of recurrent or severe hypoglycemia [Grade D, Consensus]
IA
Diabetes; Pharmacologic Glycemic ManagementC
(see Glycemic Management  in Adults with Type 1 Diabetes in Adults with Type 1

E R of Type 2 Diabetes in Adults, for

M targeting rigorous
further discussion of drug-induced hypoglycemia)
M
• A standardized education program
avoidance of hypoglycemia C Owhile maintaining overall glycemic
control [Grade B, LevelO R
T F 2]
•
O
Increased frequency of SMBG, including periodic assessment
N hours [Grade D, Consensus]
during sleeping
• Less stringent glycemic targets with avoidance of
hypoglycemia for up to 3 months [Grade D, Level 4]
• A psycho-behavioural intervention program (blood glucose
awareness training) [Grade C, Level 3]
• Structured diabetes education and frequent follow-up
[Grade C, Level 3 for type 1 diabetes; Grade D, Consensus for type 2]
SMBG, self-monitoring of blood glucose
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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

2018
Recommendation 4
4. In people with diabetes with recurrent, or severe
hypoglycemia, or impaired awareness of hypoglycemia,
SE to reduce or
U
the following strategies may be considered
L
IA
eliminate the risk of severe hypoglycemia
C and to attempt
E
to regain hypoglycemia awareness:R
M M
•
C O targets with avoidance of
Less stringent glycemic
hypoglycemia forRup to 3 months [Grade D, Level 4]
F O
• CSII or CGM
O T or sensor augmented pump with
N and follow-up for type 1 diabetes [Grade B,
education
Level 2]
• Islet Transplantation for type 1 diabetes [Grade C, Level 3]
• Pancreas transplantation for type 1 diabetes [Grade D,
Level 4]

CGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infusion

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Recommendation 5
5. Mild to moderate hypoglycemia should be
E
treated by the oral ingestion of 15 g carbohydrate,
S
preferably as glucose or sucroseLtablets U or
C A
I orange juice and
solution. These are preferable R to
glucose gels [Grade B, Level 2]M
E
. People with diabetes
O M
should retest BG inC15 minutes and re-treat with
O R
another 15 g carbohydrate if the BG level remains
F
<4.0 mmol/LOT[Grade D, Consensus]
N
Note: This does not apply to children. See Type 1 Diabetes in
Children and Adolescents; and Type 2 Diabetes in Children
and Adolescents, for treatment options in children

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Recommendation 6
6. Severe hypoglycemia in a conscious Eperson with
US
diabetes should be treated by oralL ingestion of 20 g
C IA
carbohydrate, preferably asRglucose tablets or
ME
equivalent. BG should be
M retested in 15 minutes
O another 15 g glucose if the
and then re-treatedCwith
OR
T F <4.0 mmol/L [Grade D, Consensus]
BG level remains
NO

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Recommendation 7
7. Severe hypoglycemia in an unconscious individual
with diabetes SE U
IAL
• With no intravenous access:R C 1 mg glucagon
ME
should be given subcutaneously or
O M
intramuscularly. Caregivers or support persons
R C
should call forOemergency services and the
T F
episode O
should be discussed with the DHC team
Nas possible [Grade D, Consensus]
as soon
• With intravenous access: 10-25 g (20-50 mL of
D50W) of glucose should be given intravenously
over 1-3 minutes [Grade D, Consensus]

DHC, diabetes health-care team

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Recommendations 8-9
8. Once the hypoglycemia has been reversed, the
person should have the usual mealUor SEsnack that
is due at that time of the day toIAL
prevent repeated
R C away, a snack
E
hypoglycemia. If a meal is >1 hour
M and a protein source)
M
(including 15 g carbohydrate
O
should be consumed C
R [Grade D, Consensus]
F O
O T
N
9. For individuals with diabetes at risk of severe
hypoglycemia, support persons should be taught
how to administer glucagon [Grade D, Consensus]

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Key Messages
• It is important to prevent, recognize and treat
hypoglycemic episodes secondary to the SE use of
insulin or insulin secretagogues LU IA
• It is safer and more effective to C
Rprevent hypoglycemia
E
M so people with diabetes
than to treat it after it occurs,
M
who are at high risk for C Ohypoglycemia should be
O R
T F
identified and counselled about ways to prevent low
blood glucoseNO
• It is important to counsel individuals who are at risk
of hypoglycemia and their support persons about the
recognition and treatment of hypoglycemia

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Key Messages
• The goals of treatment for hypoglycemia are to detect
and treat a low BG level promptly by using an
intervention that provides the fastest rise SEin blood
L U
glucose to a safe level, to eliminateIA the risk of injury and
R C the hypoglycemia has
to relieve symptoms quickly. Once
ME
been reversed, the person M should have the usual meal
O time of the day to prevent
or snack that is due atCthat
OR
F
repeated hypoglycemia. If a meal is >1 hour away, a
T15 g carbohydrate and a protein source)
O
snack (including
N
should be consumed
• It is important to avoid overtreatment of hypoglycemia,
since this can result in rebound hyperglycemia and
weight gain
BG, blood glucose
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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Key Messages for People with

Diabetes
SE
• Know the signs and symptoms of a low
L U blood glucose
level. Some of the more common C IA
symptoms of low
blood glucose are trembling, E R
sweating, anxiety,
M M
C O
confusion, difficulty concentrating or nausea. Not all
symptoms will be O R
present and some individuals may
have other or noT Fsymptoms
N O
• Carry a source of fast acting carbohydrate with you at
all times such as glucose tablets, lifesavers and/or a
juice box

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2018 Diabetes Canada CPG – Chapter 14. Hypoglycemia

Key Messages for People with

Diabetes
SE
L U
• Wear diabetes identification (i.e. aAMedicAlert®
C I
bracelet) E R
• Talk with your diabetesO MM
health-care team about
R C
prevention and emergency treatment of a severe low
F O
blood glucose associated with confusion, loss of
T
NO or seizure
consciousness

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Visit guidelines.diabetes.ca

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L U
C IA
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O MM
R C
F O
O T
N

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Or download the App

SE
L U
C IA
E R
O MM
R C
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N

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Diabetes Canada Clinical
Practice Guidelines
SE
L U
www.guidelines.diabetes
C IA
.caER
M M
– for health-care
C O providers
R
T FO
NO
1-800-BANTING (226-
8464)

www.diabetes.ca – for
people with diabetes
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