It’s scary to think about severe hypoglycaemia, but it can happen to anyone who manages their diabetes with insulin or sulfonylureas.
If you have type 2 diabetes and use one of these medications, you should know what severe hypoglycemia is, how to avoid it when possible, and how to treat it when it occurs. Ideally, these conversations should be happening during check-ups with members of your healthcare team.
“Unfortunately, I think the data tells us that more often than not, conversations about hypoglycaemia are not happening,” said Dr. Rozalina McCoy, an endocrinologist at the Maryland School of Medicine.
This is part of the reason so few people at risk of severe hypoglycaemia are prepared for it if and when it occurs. One study found that only 3.5% of people who treat type 2 diabetes with insulin filled a prescription for glucagon between 2019 and 2023. If no one on your healthcare team has mentioned severe hypoglycaemia or ready-to-use glucagon, it’s a good idea to bring up at your next visit.
Defining severe hypoglycaemia
A hypoglycaemic event is a problematic dip in your blood sugar. All lows should be taken seriously and treated appropriately, but some are more severe than others. Level 1 hypoglycaemia, the mildest form, is typically defined as a blood sugar level below 70 mg/dL.
Symptoms like dizziness, shakiness, sweating, hunger, and anxiety may occur during hypoglycaemia, but they become more common when levels drop below the level 2 threshold of 54 mg/dL. It’s important to note that some people have impaired awareness of hypoglycaemia and never experience symptoms, leaving them unaware of lows unless they’re using a monitor to track their blood sugar.
Level 3 or severe hypoglycaemia is when your ability to function is impaired, and you require assistance from another person to return to normal blood sugar levels. Often, this is thought of as something that occurs after you’ve reached level 2, but everybody has a different tolerance for lows.
“You can have someone have a blood sugar of 20 mg/dL, and yet they’re young and resilient and able to self-treat,” McCoy explained.
On the other hand, she said that older people, especially those who have developed additional chronic conditions that make daily life more difficult, may require medical attention for blood sugar levels as high as 70 mg/dL.
When does severe hypoglycaemia occur?
Most cases of severe hypoglycaemia are associated with insulin therapy or sulfonylureas. These medications are very effective at helping your body manage blood sugar, but it’s still easy to run into unexpected circumstances (maybe a delayed or missed meal or strenuous physical activity) that leave you with lower blood sugar than you were anticipating.
“It’s a mismatch between insulin requirements and insulin presence in the body, but it doesn’t mean it was anyone’s fault,” McCoy added.
Monitoring for lows
According to the American Diabetes Association’s (ADA) Standards of Care, everyone who takes insulin should wear a continuous glucose monitor (CGM). These devices help track changes in your blood sugar over time and alert you when you start to go low.
You should discuss your target range with your healthcare provider. Generally speaking, most people with diabetes should be aiming to spend most of their time between 70-180 mg/dL, but McCoy said she advises her older patients who might have a harder time handling a low to treat 100 mg/dL as their lower bound.
If you worry about being overwhelmed by all the CGM data, McCoy suggested thinking about it as an alert for lows. Even if you’re not looking at it that often, a CGM will tell you if you’re consistently going below your target range and may need to adjust your insulin therapy.
A CGM can be helpful for anyone with diabetes, but if someone isn’t taking insulin, then monitoring their blood sugar with fingerstick tests can be sufficient.
“If they’re on a sulfonylurea, they should check whenever they’re not feeling well or whenever they think they might be having a low,” McCoy said.
Hypoglycaemia preparedness
When you go low, the ultimate goal is to get more sugar in your body. Even if you have a severe episode that requires a trip to the hospital, healthcare providers will be treating you primarily with oral carbohydrates or an intravenous (IV) drip of sugar.
If you’re alert and able to eat, then candy, soda, juice, and even honey and sugar packets can all be effective options for raising your blood sugar back to normal levels. Wherever you are, you should always have some sort of sugary drink or snack on hand.
Regardless, there may be times when you go too low too quickly to raise your blood sugar with food. In these cases, emergency glucagon is necessary. There’s also a chance that a hypoglycaemic emergency will move so quickly that you won’t have time to react to it on your own. It’s important to educate people you’re close to about hypoglycaemia and glucagon.
In case none of them are around when you need help, you should also wear a medical alert necklace or bracelet that clearly states you have diabetes and may be experiencing a low. If you have a car, then you could also put a medical alert cover on your seatbelt.
When to use ready-to-use glucagon
The ADA recommends self-administering ready-to-use glucagon if 15 grams of sugar hasn’t resolved your low within 15 minutes, if you can’t keep food down, or if you feel yourself becoming confused or on the verge of passing out.
If you do need to give yourself glucagon, be prepared to feel sick. Also, make sure to call your healthcare provider or 911. You may still need emergency medical attention or your diabetes medications adjusted.
The ADA also recommends using glucagon if you pass out, but someone else needs to administer it at that point. Make sure your diabetes emergency kit includes glucagon and is accessible and clearly marked for other people. Once again, you should start by making sure that people you’re close to know what glucagon is, how to use it, and where your supply is stored, but you also have to anticipate times when people you’re less familiar with will need to help you.
Make sure your glucagon is clearly labelled as something to use when you’re unresponsive. If you also carry insulin with you, store the two medications in separate containers and make sure the insulin is clearly labelled as something that should not be given to you while you’re unresponsive.
It’s possible that the person who finds you might not be comfortable giving you glucagon. However, McCoy said that a dose of glucagon is unlikely to cause much harm, even if hypoglycaemia isn’t ultimately the reason a person with diabetes has become unresponsive.
Actual instructions for using glucagon will depend on what type you have. There are currently three options. A traditional mixing kit includes a vial of glucagon powder and a syringe of liquid, and the powder must be dissolved into the liquid at the time of administration. This takes time and creates the possibility for mistakes, so traditional mixing kits are not the best option for an emergency situation.
Instead, it’s better to have ready-to-use glucagon. When you talk to your healthcare provider, ask about Gvoke HypoPens and Baqsimi nasal powders, both of which are readily administered with no mixing required.
How to get glucagon
Glucagon is a prescription medication, so you’ll need to talk to a healthcare provider to get it. Ideally, when you receive a prescription for insulin or a sulfonylurea, you should also get one for glucagon. However, getting started on any new medication may involve a steep learning curve, and discussions about glucagon often slip through the cracks at early medical appointments.
“I’m not perfect. I run out of time, or I start insulin, and then I’m like, ‘Okay, I’ll talk about glucagon at the next visit,’” McCoy said.
If the clinician who prescribed you insulin or a sulfonylurea didn’t discuss glucagon, then ideally your pharmacist would bring it up when you go to fill your prescriptions. Pharmacists are legally obligated to offer consultations to anyone picking up medications, and they should know all of the risks and benefits of medications they’re dispensing.
If your pharmacist sees your insulin prescription come in without a glucagon prescription, then they should ask you about it. Your pharmacist can also ask your clinician to prescribe glucagon without waiting until your next appointment.
Other members of your healthcare team, including diabetes educators and dietitians, can also get the ball rolling on a glucagon prescription, but if no one brings it up, don’t be afraid to initiate the conversation. For many people, pharmacists may be the best starting point for these conversations because you can walk into a pharmacy and request a consultation without an appointment.
For most people in the U.S., McCoy said that insurance will cover a new prescription of an autoinjector pen or a nasal powder, but coverage varies. If your plan doesn’t cover ready-to-use glucagon and you can’t afford it on your own, you may be eligible for patient assistance programs offered by Baqsimi and Gvoke.
In general, insurance will cover a glucagon refill every year or after every use. Glucagon doesn’t last forever, so even if you haven’t used yours, make sure to check the expiration date and replace it when necessary. You’ll need a replacement every two or two and a half years depending on which option you choose.
The bottom line
Any person with type 2 diabetes may experience low blood sugar, but people who take insulin or sulfonylureas are particularly at risk for severe hypoglycaemia, which a person cannot resolve on their own without assistance from someone else. It’s important to regularly monitor your blood sugar and prepare for unexpected lows by carrying sugary snacks, a medical alert identification tag, and clearly labelled ready-to-use glucagon.
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