How to treat mild hypoglycemia

You stop what you are doing and sit down if you can. You take fast-acting carbohydrate, preferably glucose. You wait 15 minutes, then measure your glucose again with the meter [1]. This page is about mild hypoglycemia, the kind you treat on your own. The severe form, where you can no longer swallow, calls for glucagon and help from the people around you, and its treatment is described separately.

What you do not do matters just as much. You do not carry on driving, swimming or working at height. You do not give yourself insulin during this time. You do not eat everything you can find, because the result will be a high glucose an hour later, followed by a correction and sometimes by another low. There are only three steps and their order matters, as the figure below shows.

It is the most widely used rule in diabetes education. You take 15 g of fast-acting carbohydrate, wait 15 minutes and measure your glucose. If you are still below 70 mg/dL (3.9 mmol/L), you repeat exactly the same thing once more.

The strength of the rule is its simplicity. It can be held in mind during a low, when thinking slows down. The numbers are not a guarantee, though. When treatment starts below the 70 mg/dL (3.9 mmol/L) threshold, 69% of people need more than one round [2]. The amount is adjusted with your doctor according to weight, age and the type of treatment.

For an adult, 15 g is the standard amount. That means roughly three glucose tablets or 150 ml of fruit juice. What counts is the glucose content of the food, not the total carbohydrate, so pure glucose is the first choice [3].

The amount of carbohydrate needed to treat a mild low changes in some situations. Children need less, in proportion to their weight. People on an automated insulin delivery system also need less. The reason there is that the system has already reduced or even stopped insulin delivery some time earlier. In both cases 15 g can push glucose somewhat too high straight after treatment.

Fifteen minutes. That is the time glucose needs to leave the stomach, reach the blood and lift your reading [1]. Any earlier and you will not see much, and the number can frighten you for nothing. Do not restart treatment sooner, however unpleasant it feels, because rounds that are too close together overlap and send you into hyperglycemia.

If you are looking at a sensor, wait longer. The sensor value rises a few minutes after blood, so at 15 minutes it can look as if nothing has happened [4]. This is the most common reason people overtreat a low. For this interval, the meter gives the right answer.

You repeat the same amount and wait another 15 minutes. You do not double it and you do not switch to something else. Most episodes settle after the first or the second round.

It is also worth checking what you ate. Chocolate and ice cream contain fat that delays absorption, while cookies are solid and hard to count. As a result they do not work well as emergency treatment. Sugar-free drinks contain no carbohydrate at all [5]. If you took something from these groups, the first round was wasted.

Two or three times. If your glucose still does not rise after three correctly done rounds, the situation is no longer ordinary and you need help [6]. You ask for medical assistance and carry on trying on your own in the meantime.

There are three usual reasons why a mild low does not correct:

• An insulin dose far too large for the amount of carbohydrate in that meal.
• Drinking alcohol, which blocks glucose production in the liver [7].
• A delivery error, such as confusing rapid-acting insulin with basal insulin.

In these situations the low can drag on for hours and needs medical supervision. Tell someone near you if you are in such a situation. If confusion or drowsiness appear, emergency services must be called.

Yes. For these patients 5 to 10 g of carbohydrate is recommended, compared with 15 g for most other people. The reason is that the system has already stopped or reduced insulin delivery some time earlier, so part of the job has been done for you [8].

There are two exceptions where you still use the usual 15 g. The first is a low during or after exercise. The second is when you clearly overestimated the carbohydrate in a meal and gave too large a bolus. When active insulin far exceeds what you need at that moment, the low is treated with 15 g [9].

Yes, especially in children. About 0.3 g of glucose per kilogram is recommended in that case [10]. A child of 30 kg needs roughly 9 g of carbohydrate, and above 50 kg you reach 15 g, the adult amount.

The logic is simple. The same amount of glucose lifts a smaller body's glucose more, because it is spread through a smaller volume. In a child of 20 kg, 15 g often produces a glucose that is too high after treatment. The right amount clears the low without creating the next problem, hyperglycemia.

Yes, and ideally completely. You stop and sit down until your glucose is back above the 70 mg/dL (3.9 mmol/L) threshold. Exercise burns the glucose you have just taken and drags the episode out. You do not swim, climb a ladder or work with machinery until you have a confirmed value above the threshold [1].

If a low happens during exercise, you stop the activity, take fast-acting carbohydrate and go back to it only once your glucose is back in your target. Remember that the risk of another low stays high for several hours after training, not only during it [11].

You pull over, turn off the engine, treat and wait. Driving performance is already impaired at values just above the hypoglycemia threshold, and drivers usually put off treating until they are very low [12]. Do not start driving with a glucose below 90 mg/dL (5.0 mmol/L), because the value can change a great deal in the first 20 minutes of a trip [13].

You wait at least 45 minutes after your measured glucose is back to normal, not only until the number comes up. Attention takes longer to recover after a low than glucose does [14]. Keep a glucose supply and your meter in the car, because during a low you have neither the patience nor the clarity to rummage through drawers.

The treatment is the same by day and by night, that is 15 g of fast-acting carbohydrate and a fresh reading 15 minutes later. The difference is that at night you first have to wake up. Sensor alarms become extremely valuable in this case [15].

Systems that automatically stop insulin delivery when they predict hypoglycemia significantly reduce the number of nighttime episodes [8]. The answer is not to eat extra in the evening to be on the safe side, but to discuss your insulin doses with your medical team.

Above 70 mg/dL (3.9 mmol/L) and steady. You do not need a high value to be safe. A glucose of 90 or 100 mg/dL (5.0 or 5.6 mmol/L) that is no longer falling is a very good result.

If rapid-acting insulin is still active and the next meal is far away, add slower carbohydrate, such as a slice of bread or a yogurt [1]. Do not give yourself insulin to repair the rise that follows treatment, because that is where most needless corrections happen. Write the episode down, with the time, the value and the active insulin, then discuss it at your next appointment.