Jay H. Shubrook, DO; Joy A. Dugan, MS, PA-C, MPH


August 03, 2017

Jay H. Shubrook, DO: Hi, I am Jay Shubrook, family physician, diabetologist, and professor at Touro University, California. Today we are continuing our series on practical insulin use in primary care.

When talking about insulin, one of the most important topics we need to discuss is hypoglycemia. We have brought back Joy Dugan, MS, PA-C, MPH, who is also a faculty member at Touro University, California, to talk about this important topic.

Thank you for coming back to the program, Joy.

PA Dugan: Good morning.

Treating Hypoglycemia: The 15/15 Rule

Dr Shubrook: During our previous session, we talked about hypoglycemia and how to identify it. Today, I would like to focus on the treatment of hypoglycemia. First of all, how do you define hypoglycemia?

PA Dugan: Hypoglycemia is defined as a blood sugar level below 70 mg/dL.[1] This can occur with or without symptoms.

Dr Shubrook: Hypoglycemia is very common in people with diabetes, and even more common in people taking insulin. How do people treat hypoglycemia?

PA Dugan: One of the most useful mnemonics you can teach a patient on insulin or with diabetes, especially those taking insulin, is the "15/15 rule." What that stands for is, at onset of hypoglycemia symptoms or if their glucometer number reads below 70 mg/dL, they should consume 15 g of carbohydrates [then wait 15 minutes and recheck their glucose level].

This is a really important time to introduce food labels, because your patients are not necessarily going to know how to read a food label. Examples of 15 g of carbohydrates include half a can of regular soda (not diet soda), half a cup of juice, and three to four glucose tablets.

It is important that you teach patients to use three to four glucose tablets, because one glucose tablet only has about 4 g of carbohydrates. If individuals are not informed of this, they will only take 1 tablet, thinking they are doing the job. They are not going to raise their blood sugar sufficiently. Premade glucose gels also come in about 15-g little packets.

I also recommend patients to have juice boxes of any brand on hand. I do know that a Juicy Juice® box contains about 14 g of carbohydrates. These are really easy to have.

Some patients like to have candy bars or other hard candies. However, I feel hypoglycemia is a medical issue and should be treated medically. I prefer that patients use glucose tablets or glucose gel in lieu of a candy bar. We want them to use the most readily available source of carbohydrates—glucose. Candy bars have other macronutrients within them.

Dr Shubrook: That is a really important point. It seems like all of my patients want to use peanut butter crackers. Peanut butter crackers may not be the best option, for the same reason.

PA Dugan: Correct, because that is going to have protein and fat in addition to complex and simple carbohydrates. You really want to aim for that simple carbohydrate of glucose. Again, such things as juice or glucose tablets tend to be the most readily available.

A lot of patients will say that they ate a banana or a piece of fruit. Even those need a little bit more processing by the body. I try to steer patients toward using glucose tablets, soda, or juice.

Dr Shubrook: I love that you gave examples, because it seems that my patients never have their treatments for hypoglycemia with them. Something portable is very important—for example, a juice box, glucose tablets, or even Life Savers®. I think six Life Savers is about 15 g [of carbohydrates]. Do you ever give lists of examples to patients?

PA Dugan: I do. One of the handouts I generally give patients has the symptoms of hypoglycemia, examples of what contains 15 g of carbohydrates, and the 15/15 rule.

After consuming 15 g of carbohydrates, the next part of the rule is to wait 15 minutes, then recheck [the blood sugar level]. If you are still below 70 mg/dL, you should self-correct again and recheck in 15 minutes. Continue this process until your blood sugar is above 70 mg/dL. If it is getting close to mealtime, [then] I recommend, after self-correcting to over 70 mg/dL, that you begin your meal preparation and consume your meal.

Dr Shubrook: Fifteen minutes feels like a very long period of time when you are hypoglycemic, so it's all the more reason to make sure your patient takes an adequate first treatment sample so they have a chance to feel better. Otherwise, if I drop low, I could probably eat 5000 calories in 15 minutes. That is why pure glucose will help you feel better quicker.

I also get a lot of questions about glucagon. When and where do we use glucagon?

What About Glucagon?

PA Dugan: Glucagon should be given, in my opinion, to anybody who is on insulin or has had a severe hypoglycemic event that needed assistance. I prescribe glucagon in those cases. It is not for self-administration by the patient; it is administered to the patient by family members, housemates, and friends. It is no longer self-administering.

It is important that these friends and family members learn how to use the glucagon pen and know the signs and symptoms of hypoglycemia so that they can encourage the patient to self-treat initially. If the patient is unable to self-treat—for example, they are unconscious or are unable to open the bottle of glucose tablets—then their family member should treat them with glucagon.

Dr Shubrook: You shared such important things today. Number 1 [is] remember the rule of 15s when you are treating hypoglycemia: Eat 15 g of fast-acting glucose, and recheck in 15 minutes. Number 2 [is that] glucagon is an important treatment for anybody on insulin, but it is meant to be given by someone other than the person themselves. People should not give themselves glucagon. That requires the people around somebody with diabetes to learn how to do the glucagon injection.

Thank you so much for being here today, Joy, and sharing these good insights.


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