A panel of thought leaders in the management of diabetes reviews the mainstays of treatment for hypoglycemic episodes and builds a discussion on effective non-pharmacologic strategies for raising blood glucose levels.
Peter Salgo, MD: Once you identify the problem, the next question that comes up, of course, is what do we do about it? How do you manage it? I’ll ask a real softball question: What’s the mainstay in therapy for the management of hypoglycemia, Jay?
Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: The first part is prevention, right? Prevention is always the first part, but if someone actually has hypoglycemia, the answer depends on where you’re at. For a mildly symptomatic form of hypoglycemia, it could be the rule of 15s. If it’s a severe hypoglycemic episode, which is really our focus, it’s going to be glucagon in the outpatient setting. If it’s in the hospital, it might be dextrose. One of the things we want to make sure everyone takes from this is that every patient who’s at risk for severe hypoglycemia should have access to glucagon.
Peter Salgo, MD: You lost me just for a moment. What’s the rule of 15s?
Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: The rule of 15s is that people who are having symptoms of hypoglycemia—hopefully this is confirmed with a low blood glucose—would have 15 g of a rapid-acting glucose, and they would recheck their sugar in 15 minutes. Anne highlighted this earlier; when you’re low you need anything you can get access to, and that’s what causes rebound hyperglycemia. Most people can get away with 15 g—maybe 30 g—of glucose. That would treat most forms of hypoglycemia safely, but we need to have a preglucose measurement and a postglucose measurement, so we know the person is actually improving.
Peter Salgo, MD: We have guidelines out there, right? Nudge, nudge, wink, wink—Anne, there are guidelines published for the management of hypoglycemia in patients with diabetes. What are these guidelines? Are they simply the rule of 15s? How do you approach this whole problem?
Anne Peters, MD: There’s the rule of 15s to start, if somebody is conscious and able to ingest carbohydrate, but they do say that anybody who’s at risk for level 2 or 3 hypoglycemia should have glucagon available to them. Frankly, anybody who’s on insulin—whether it’s someone with type 1 or type 2 diabetes—in my mind is at risk for level 2 or 3 hypoglycemia, so they should have glucagon at home. It also needs to be unexpired glucagon, and some other human being needs to know where it is because it’s really not useful if someone can’t find it, if it’s expired, or if the person having hypoglycemia doesn’t know what to do. The guidelines are very simple about how to treat it. I also want to point out when somebody, for instance, is having a seizure or something is happening, you shouldn’t try to put sugar in their mouth. I have this happen all too often. This is when you want to give potentially injected glucagon because it may be hard to deal with the patient when they’re having a real problem. There’s also intranasal glucagon, which we’re going to talk about, but people need to get glucagon. We really need to not try to stuff carbohydrates down their mouth if they can’t swallow.
Peter Salgo, MD: You don’t want to compound hypoglycemia with aspiration or pneumonia, I would think.
Anne Peters, MD: Correct.
Peter Salgo, MD: Is there a nonpharmacological method of management of hypoglycemia? Can you say that there’s nonpharmacological management of severe hypoglycemia? Does that make any sense at all, Davida?
Davida Kruger, MSN, APN-BC, BC-ADM: I think Anne pointed out that if you can’t swallow, we don’t want anyone to try to give you anything by mouth, and that’s when glucagon is going to come in. We really do have patients, or we talk with patients, to make sure they always have something with them to treat low blood sugar. I’m guilty of it—Amazon will send glucose tablets directly to people’s houses for $3 for a big bottle. I’ve been doing that to some of my patients as a surprise because I want them to use glucose tablets instead of having them eat everything. I call it refrigerator syndrome: You open the refrigerator, sit down, and eat until you feel better. I had a woman come in last week who had gained 12 pounds in 6 weeks, and we figured out she was treating each hypoglycemic event with 1000 calories, and she was having them 3 times a day.
Peter Salgo, MD: I don’t know if you can see Elaine’s face.
Davida Kruger, MSN, APN-BC, BC-ADM: I can, yes. That’s a true story. Of course, obviously I’m trying to figure out, first, what’s causing the hypoglycemia but also how she’s treating it that would cause her to gain—legitimately gain—12 pounds. What I would say to you is that I’m going to go back to the 15s rule. We really talk to patients about what 15 g of carbohydrates look like. When you’re having hypoglycemia, that’s not the time to say, “I’m going to eat a candy bar because I really like candy bars.” We want patients to hold that and fit it into their daily routine if they really want a candy bar. We can work around that because chocolates and fat delay the emptying and all this good stuff, and they’re not going to get what they want. The nonpharmacological method would be glucose tablets, or a glucose gel, or I have seen families use frosting—you know, the gel frosting. Those are things patients can quickly eat and swallow. They have a half of a little Life Saver, a half a can of juice, or soda pop, or milk—those are what we would use for nonpharmacological treatment, assuming the patient can swallow.
Peter Salgo, MD: Yeah, I was going to ask you about the juice. The old saw about is orange juice: “I felt terrible. I had a glass of orange juice. I felt better.” I guess that’s in your armamentarium too.
Davida Kruger, MSN, APN-BC, BC-ADM: The problem is that we’re talking about 2 to 4 oz of orange juice, and a lot of times in the hospitals we used to see 8 to 10 oz in at least 4 or 5 packs of sugar for a hypoglycemic event. That’s what we don’t want to happen. We really want to line up things that have 15 g of carbohydrates, and we really do give patients a list of things to pick from and what can fit in your pocket, briefcase, or suitcase that you could quickly take: like hard candy, or whatever it is that you could quickly take. That’s for the individual to take themselves or even something that a family member can offer. That’s the other thing: If the patient still can swallow, a family member or a friend can see that there’s a difference in that individual and may offer something and say, “Are you low? Do you have low blood sugar? Did you want to take a glucose tablet?”
Elaine Apperson, MD: I try to emphasize to families that you’ve got to get the sugar from the stomach into the blood as quickly as possible to cut off what could be a rapidly dropping blood sugar. I try to have them picture their child’s stomach like a colander. You don’t want to put a candy bar or a peanut butter cracker in there and pour hot water over it and see how long it takes to get through those tiny holes. You want to put juice, or glucose gel, or something total unimpeded by protein and fat in there, so it gets through as quickly as possible. Even Skittles are not going to be impeded by protein and fat. That’s the most important part. Let that glucose rise and then give them milk and peanut butter crackers to then allow some protein, fat, and carbohydrates to keep the glucose up for a longer period. When I come in and they’ve had a low blood sugar and the child just ate a peanut butter and jelly sandwich to treat it, sometimes I want to crawl under the exam table. I try to have them visualize it: we must get the sugar to the blood fast, and there are certain things—glucose tablets dissolve instantly. They may not taste great—the child may not like it—but tough luck. Sometimes they eat peanut butter cups. Well, that’s not a good treatment for low blood sugars.
Peter Salgo, MD: By the way—this is almost a non sequitur—as I was listening to you folks, you reminded me of a case I had many years ago. We had a ballet dancer—as you know, their bodies tend to be very thin—who was suddenly gaining weight uncontrollably. When we asked what she was doing, she said, “Every time I feel bad, I eat. Every time I feel bad, I drink juice.” It turned out she had an insulinoma.
Elaine Apperson, MD: Yes, yes, yes.
Peter Salgo, MD: It’s about treating. There’s a point to this. It’s treating the hypoglycemia with something you really shouldn’t be. In the diabetic case, it would be the insulin that you’re giving the patient, but it can happen with any hypoglycemic episode, I guess.
Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: I would add that the most important part of this is that luck favors the prepared. If you don’t have those things with you, you’re going to default to whatever you find. Having glucose tablets—and Elaine, I love your point, they don’t taste that great to most people, which means you’re likely to have them when you need them in an emergency. If it’s a package of Skittles or Life Savers, I might snack on those when I’m not low, and I might not have them when I need them. It’s really important that you prepare, so that you have what you need.
Peter Salgo, MD: Is it reasonable to think about giving nonpharmacological treatment to people with severe hypoglycemia, or is this always pharmacology?
Davida Kruger, MSN, APN-BC, BC-ADM: It’s always pharmacology.
Peter Salgo, MD: I want to thank all of you for watching this HCPLive® Peer Exchange. If you enjoyed the content, I want you to subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box.
Transcript Edited for Clarity