GUIDELINE FOR THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS WITH DIABETES MELLITUS

GUIDELINE FOR THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS WITH DIABETES MELLITUS Guideline author Accountable Executive Lead Approving body Policy reference Diabetes Specialist Nurse Consultant Diabetologist Clinical Director Directorate Governance Group Drugs and Therapeutic Committee SWBH/Diab/017 Overall purpose of the guideline Guideline for the Management of Hypoglycaemia in Adults with Diabetes Mellitus in Hospital Principal target audience Clinicians in Hospital Application In Adults with Diabetes Mellitus in Hospital Scope Guideline for the Management of Hypoglycaemia In Adults with Diabetes Mellitus in Hospital National Guidance incorporated DOCUMENT CONTROL AND HISTORY n/a Version No Date Approved Date of implementation Next Review Date Reason for change (e.g. full rewrite, amendment to reflect new legislation, updated flowchart, etc.) 2 June 2006 June 2006 June 2007 3 25-02-2011 25-02-2011 31-08-2013 No changes 3 August 2014 August 2014 May 2016 4 July 2017 July 2017 July 2019 Updated Guidelines for the management of Hypoglycaemia in Adults Page 1 of 10

Management of hypoglycaemia in adults (aged 18 years or over) with diabetes mellitus within the hospital setting Contents 1.0 Introduction 3 2.0 Definitions. 3 3.0 Clinical Features. 3 Page 3.1 Symptoms of Hypoglycaemia. 3 4.0 Risk Factors for Hypoglycaemia. 4 5.0 Causes of Inpatient Hypoglycaemia. 4 6.0 Treatment of Hypoglycaemia 5 6.1 Adults who are conscious and able to swallow 5 6.2 Adults who are Unconscious/having seizures/aggressive. 5-6 6.3 Adults who are Nil by Mouth.. 6.4 Adults requiring enteral feeding. 7.0 When hypoglycaemia has been successfully treated 8.0 References.. Appendix 1 Appendix 2 Examples of contents for Hypo Box.. Traffic light algorithm for treatment of hypoglycaemia - Conscious Patients able to swallow - Unconscious or aggressive Patients Guidelines for the management of Hypoglycaemia in Adults Page 2 of 10

1.0 Introduction This guideline is for the management of hypoglycaemia in adults (aged 18 years or over) with diabetes mellitus within the hospital setting. Hypoglycaemia is the commonest side effect of insulin and sulphonylureas in the treatment of diabetes and presents a major barrier to satisfactory long term glycaemic control. Metformin, pioglitazone, the DPP-4 inhibitors, SLGT-2 inhibitors and GLP-1 analogues prescribed without insulin or sulphonylureas therapy are unlikely to result in hypoglycaemia. Hypoglycaemia results from an imbalance between glucose supply, glucose utilisation and current insulin levels and should be excluded in any person with diabetes who is acutely unwell, drowsy, unconscious, unable to co-operate, presenting with aggressive behaviour or seizures. The brain is dependent on a continuous supply of glucose and its interruption leads to central nervous system dysfunction, impaired cognition and eventually coma. If hypos are prolonged, they can result in death. Hypoglycaemia results from an imbalance between glucose supply, glucose utilisation and current insulin levels and should be excluded in any person with diabetes who is acutely unwell, drowsy, unconscious, unable to co-operate, presenting with aggressive behaviour or seizures. The brain is dependent on a continuous supply of glucose and its interruption leads to central nervous system dysfunction, impaired cognition and eventually coma. If hypos are prolonged, they can result in death. 2.0 Definition Hypoglycaemia is a lower than normal level of blood glucose. It can be defined as mild if the episode is self treated and severe if assistance by a third party is required (DCCT, 1993). For the purposes of people with diabetes in hospital, any blood glucose less than 4.0mmol/L should be treated with or without symptoms. If blood glucose level is below 2.8mmols a venous laboratory glucose is required. 3.0 Clinical Features The symptoms of hypoglycaemia warn an individual of its onset and vary considerably between individuals. The 11 most common symptoms used to form the Edinburgh Hypoglycaemia Scale and are reproduced in the below table (Deary et al 1993). 3.1 Edinburgh Hypoglycaemia (Hypo) Scale Autonomic Neuroglycopenic General Malaise Sweating Confusion Headache Palpitations Drowsiness Nausea Shaking Odd behaviour Hunger Speech difficulty Incoordination If a person with diabetes displays or expresses any symptoms of hypoglycaemia, do not delay in taking a capillary blood glucose measurement Note: Some patients, particularly those with longstanding diabetes, may lose their hypo awareness. Symptoms may be less obvious in the elderly. Guidelines for the management of Hypoglycaemia in Adults Page 3 of 10

4.0 Risk Factors for Hypoglycaemia Medical Issues Strict glycaemic control Previous history of severe hypoglycaemia Long duration of type 1 diabetes Duration of insulin therapy in type 2 diabetes Lipohypertrophy (lumpy) injection sites Impaired awareness of hypoglycaemia Severe hepatic dysfunction Renal failure (on dialysis) Acute Kidney injury Impaired renal function Inadequate treatment of previous hypoglycaemia Terminal illness Bariatric surgery involving bowel resection Lifestyle Issues Increased exercise (relative to usual) Irregular lifestyle Increasing age Alcohol Early pregnancy Breast feeding No or inadequate blood glucose monitoring Reduced carbohydrate intake Food malabsorption e.g. gastroenteritis, coeliac disease. 5.0 Potential Causes of Inpatient hypoglycaemia Common causes of inpatient hypoglycaemia are listed below however one of the most serious and common causes of inpatient hypoglycaemia is insulin prescription error; misreading poorly written prescriptions when U is used for units (4U becoming 40 units). For this reason the insulin prescription chart must be used when prescribing s/c insulin. 5.1 Common Causes of inpatient hypoglycaemia Medical Issues Inappropriate use of stat or PRN rapid/short acting insulin Major amputation of limb Acute discontinuation of long term steroid use Recovery from acute illness/stress Mobilisation after illness Inappropriately timed diabetes medication/insulin for meal/enteral feed Incorrect insulin/diabetes medication prescribed and administered Change of insulin injection site IV insulin infusion Inadequate mixing of intermediate or mixed insulins Regular insulin doses and/or diabetes medication being given in hospital when they are not routinely taken at home Reduced Carbohydrate intake Change of timing of the biggest meal of the day i.e. main meal at midday rather than evening Missed or delayed meals Less carbohydrate than usual Lack of access to usual between meal or before bed snacks Vomiting Prolonged starvation time e.g. nil by mouth Reduced appetite Reduced carbohydrate intake Guidelines for the management of Hypoglycaemia in Adults Page 4 of 10

6.0 Treatment of Hypoglycaemia There must always be readily available/easily accessible rapid and long acting carbohydrate treatments in your clinical area. The use of a hypo box is standard good practice (Barker et al 2007).These boxes should be placed in a prominent place e.g. resuscitation trolleys, suggested contents of a hypo box can be found in appendix 1. Note: Adults who have poor glycaemic control may start to experience symptoms of hypoglycaemia but have a blood glucose level greater than 4mmol/l treat with a small carbohydrate snack only (for symptom relief) e.g. 1 medium banana, a slice of bread or normal meal if due. 6.1 Adults who are conscious, orientated and able to swallow 6.1.1 Give 15 20 grams of quick acting carbohydrate use only one of the following options 1 bottle glucose juice - a measured drink containing 15 g of carbohydrate such as glucojuice 5 7 glucose tablets (3 grams carbohydrate per tablet such as dextro tablets) 20 g glucose gel (2 x 10 gram tubes such as glucogel) 6.1.2 If blood glucose remains less than 4mmol/l after 30-45 minutes or 3 cycles, contact a doctor. Consider o 1 mg of glucagon im (may be less effective in patients prescribed sulphonylureas therapy/patients currently under the influence of alcohol/prolonged starvation) Or o IV 10% glucose 200ml over 15 minutes. 6.1.3 Once blood glucose is above 4 mmol/l and the patient has recovered, give 20 g longacting carbohydrate of the patient s choice where possible. Some examples are: Two plain biscuits One slice of bread/toast 200 300 ml glass of milk (not soya) Normal meal if due (must contain carbohydrate) 6.1.4 Recheck capillary blood glucose after 1 hour to ensure success of treatment. Ensure capillary blood glucose level monitoring is continued for 24 to 48 hours-fasting; pre meals; before bed. 6.1.5 After Hypo is corrected and blood glucose is above 4 mmols administer usual diabetes medication / insulin injection if due (dose review may be required). 6.1.6 Refer to Think Glucose all patients with severe hypoglycaemia or repeated (more than 2 episodes) hypoglycaemia. 6.1.7 Document in the patient s record. 6.2 Adults who are unconscious and/or having seizures and/or are very aggressive 6.2.1 Check: Airway Breathing Circulation Disability Exposure Call EMRT if required If the patient has insulin infusion in situ stop immediately Guidelines for the management of Hypoglycaemia in Adults Page 5 of 10

6.2.2 Establish IV access and give glucose intravenously over 15 minutes to reduce risk of extravasation injury. Either give (choose one option) I. 100 ml of 20% glucose over 15 mins (400ml/hr) Or II. 200ml of 10% glucose over 15 mins (800ml/hr) 6.2.3 If unable to establish IV access give glucagon 1 mg IM. Glucagon which may take up to 15 minutes to take effect mobilises glycogen from the liver and will not work if given repeatedly or in starved patients with no glycogen stores or those with severe liver disease. In this situation or if prolonged treatment is required, IV glucose is preferred. 6.2.4 Recheck capillary blood glucose measurement every 10 minutes to ensure response. 6.2.5 If slow/ no response call doctor immediately if not already done so. 6.2.6 Once blood glucose level is above 4 mmol/l and the patient has recovered, give 40g long acting carbohydrate of the patient s choice where possible. Some examples are: Four plain biscuits 2 slices slice of bread/toast 200 300 ml glass of milk (not soya) plus 2 plain biscuits Normal meal if due (must contain carbohydrate) 6.2.7 After Hypo is corrected and blood glucose is above 4 mmols administer usual diabetes medication / insulin injection if due (dose review may be required). 6.2.8 Recheck capillary blood glucose after 1 hour to ensure success of treatment. Ensure regular capillary blood glucose level monitoring is continued for 24 to 48 hours fasting; pre-meals; before bed. 6.2.9 Refer to Think Glucose. 6.2.10 Document in the patient s record. NOTE: If hypoglycaemia was due to sulphonylureas or overdose of insulin consider maintenance IV infusion of 10% glucose. Perform capillary blood glucose measurements using approved technique. If hypoglycaemia is prolonged confirm with venous blood glucose (laboratory) 6.3 Adults who are Nil By Mouth 6.3.1 If the patient has a variable rate intravenous insulin infusion (VRIII) adjust as per VRIII guideline. Recheck capillary blood glucose measurement every 10 minutes to ensure response. 6.3.2 Establish IV access and give glucose intravenously over 15 minutes to reduce risk of extravasation injury. Either give (choose one option) I. 100 ml of 20% glucose over 15 mins (400ml/hr) Or II. 200ml of 10% glucose over 15 mins (800ml/hr) 6.3.3 Recheck capillary blood glucose measurement every 10 minutes to ensure response. 6.3.4 Once blood glucose is greater than 4mmol/l and the patient has recovered consider 10% glucose at a rate of 100ml/hr until patient is no longer NBM or has been reviewed Guidelines for the management of Hypoglycaemia in Adults Page 6 of 10

by a doctor. 6.3.5 After Hypo is corrected and blood glucose is above 4 mmols administer usual diabetes medication / insulin injection if due (dose review may be required). 6.3.6 Recheck capillary blood glucose after 1 hour to ensure success of treatment. Ensure regular capillary blood glucose level monitoring is continued for 24 to 48 hours fasting; pre-meals; before bed. 6.3.7 Refer to Think Glucose. 6.3.8 Document in the patient s record. Note: if the hypoglycaemia was due to sulphonylureas or insulin therapy then be aware that the risk of hypoglycaemia may persist for up to 24-36 hours following the last dose especially if there is concurrent renal impairment. 6.4 Adults requiring enteral feeding Patients requiring total parenteral nutrition (TPN) should be referred to a dietician /nutrition team and think glucose for individual assessment. Risk factors for hypoglycaemia Blocked /displaced tube Change in feed regimen Enteral feed discontinued TPN or IV glucose discontinued Diabetes medication administered at an inappropriate time to feed Changes in medication that cause hyperglycaemia e.g. steroid therapy reduced/stopped Feed intolerance Vomiting Deterioration in renal function Severe hepatic dysfunction Treatment to be administered via feed tube Do not administer these treatments via a TPN line 1. Give 15-20 grams of quick acting carbohydrates of the patient s choice where possible. Some examples are o 1 bottle glucose juice - a measured drink containing 15 g of carbohydrate such as glucojuice NB all treatments should be followed by a water flush of the feeding tube to prevent tube blockage. 2. Repeat capillary blood glucose measurement 10-15 minutes later. If still less than 4mmols/l repeat step 1 (no more than 3 treatments in total) 3. If blood glucose level remains less than 4mmols/l after 30-45 minutes (or 3 cycles) consider o IV 10% glucose 200ml over 15 minutes 4. Once blood glucose is above 4mmols/l and the patient has recovered give a long acting carbohydrate. Some examples are Guidelines for the management of Hypoglycaemia in Adults Page 7 of 10

o o o Restart feed/give stat bolus feed (read nutritional information and calculate required amount to give 20 grams of carbohydrates.) If bolus feeding give additional bolus feed (read nutritional information and calculate required amount to give 20 grams of carbohydrates.) 10% IV glucose at 100ml/hr. Volume should be determined by clinical circumstances. 5. After Hypo is corrected and blood glucose is above 4 mmols administer usual diabetes medication / insulin injection if due (dose review may be required). 6. Recheck capillary blood glucose after 1 hour to ensure success of treatment. Ensure regular capillary blood glucose level monitoring is continued for 24 to 48 hours - fasting; pre-meals; before bed. 7. Refer to Think Glucose. 8. Document in patient s medical notes. Note: if the hypoglycaemia was due to sulphonylureas or insulin therapy then be aware that the risk of hypoglycaemia may persist for up to 24-36 hours following the last dose especially if there is concurrent renal impairment. 7. When hypoglycaemia has been successfully treated Consider completing an incident form if appropriate. If hypo box used replenish as appropriate Identify the risk factor or cause resulting in the hypoglycaemia. See section 4 and 5 Take measures to avoid hypoglycaemia in the future. The Think Glucose team can be contacted to discuss this. DO NOT omit the next insulin injection/diabetes medication (a dose review may be required) or start a variable rate intravenous insulin infusion to stabilise blood glucose. If unsure of subsequent diabetes treatment discuss with the Think Glucose team or Patient s own team. DO NOT treat with stat doses of rapid/short acting insulin an episode of hyperglycaemia which follows treatment for hypoglycaemia. DO NOT treat isolated spikes of hyperglycaemia with stat doses of rapid/short acting insulin. Instead maintain regular capillary blood glucose monitoring and adjust normal insulin regimen only if a particular pattern emerges. 8. An incident form must be completed in the event of any clinical incidents 9. Reference JBDS (01) Hospital management of hypoglycaemia in adults with diabetes mellitus revised sept 2013. Guidelines for the management of Hypoglycaemia in Adults Page 8 of 10

Appendix 1 CONTENTS OF HYPO BOX Copy of hypoglycaemia algorithm (Appendix 2) Initial Treatment 1-2 bottles Glucojuice (available from stores code AZB178) 2 x packets Dextrose Energy tablets (available from pharmacy) 1 box of 3 tubes of Glucogel (available from pharmacy) IM Glucagon kit stored in ward fridge Secondary Treatment Mini pack of 3 biscuits (available from catering) CHECK CONTENTS DAILY. ENSURE WITHIN EXPIRY DATE. REPLENISH ITEMS AFTER USE. Guidelines for the management of Hypoglycaemia in Adults Page 9 of 10

Appendix 2 Algorithm for the treatment of Hypoglycaemia in Adults with Diabetes in Hospital Hypoglycaemia is a serious condition and should be treated as an emergency regardless of level of consciousness. Hypoglycaemia is defined as blood Glucose of less than 4mmol/L (if not less than 4mmol/L but symptomatic give a small Carbohydrate snack for Symptom relief). Patient conscious, orientated and able to swallow Patient unconscious/fitting or very aggressive or nil by mouth (NBM) Give 15-20 g of quick acting carbohydrate, such as 1 bottle Glucojuice or 5-7 Dextro Energy tablets or 2 tubes of glucose gel Test blood glucose level after 15 minutes and if still less than 4 mmol/l repeat up to 3 times. Blood glucose level should now be above 4mmol/L. Give 20g of long acting carbohydrate e.g two biscuits / slice of bread / 200-300ml milk/ next meal if due. If IM Glucagon has been used give 40g of long acting carbohydrate. For patients with enteral feeding tube Once glucose > 4.0mmol/L restart feed / give bolus feed or start IV 10%glucose at 100ml/hr. Check ABC, stop IV insulin, contact doctor urgently or call EMRT 2222 If no IV access Give 1mg Glucagon IM If IV access give IV glucose over 15 minutes as 100 ml 20% glucose or 200ml 10% glucose * Recheck glucose after 10 minutes and if still less than 4mmol/L, repeat treatment. If glucose now above 4mmol/L, follow up treatment as described on the left. If NBM, once glucose >4.0mmol/L give 10% glucose infusion at 100ml/hr until no longer NBM or reviewed by doctor DO NOT OMIT SUBSEQUENT DOSES OF INSULIN. CONSIDER DOSE ADJUSTMENT. CONTINUE REGULAR CAPILLARY BLOOD GLUCOSE MONITORING FOR 24 TO 48 HOURS AND GIVE HYPO EDUCATION OR REFER TO THINK GLUCOSE FOR ADVICE