Suspected hypoglycaemia: check capillary glucose now
Treat if glucose is below 4.0 mmol/L (72 mg/dL). If the person is not alert and no meter is at hand, treat as hypoglycaemia.
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Hypoglycaemia Management in Adults with Diabetes
Hypoglycaemia Management in Adults with Diabetes: Suspected hypoglycaemia: check capillary glucose now → Child or adolescent: use paediatric doses, not ...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Warning Child or adolescent: use paediatric doses, not the adult doses below
Adults: go on to the next step.
- Child IV: 10% glucose 2 mL/kg IV bolus (RCH), max 200 mL (the adult dose)
- Child glucagon IM: 0.5 mg if under 25 kg; 1 mg if 25 kg or more
- Neonates: use the neonatal hypoglycaemia guideline
03Action Classify the level (ADA 2026)
Level 3 is defined by the need for help, at any glucose level.
- Level 1: 3.0 to below 3.9 mmol/L (54 to below 70 mg/dL)
- Level 2: below 3.0 mmol/L (54 mg/dL)
- Level 3 (severe): altered mental or physical state; needs another person to treat it
- Australian practice treats any glucose below 4.0 mmol/L
04Warning Stop IV insulin now; suspend an insulin pump if not alert; assess ABCDE
Unconscious or seizing: call for help now (000 outside hospital).
- Restart the insulin infusion once glucose is above 4.0 mmol/L and the hypo is treated, at a reviewed rate
- Insulin pump and not alert or cannot self-manage: suspend or remove the pump; plan other insulin with the diabetes team
- Type 1 diabetes: do not leave without insulin after recovery (risk of DKA)
05Warning Known adrenal insufficiency and unwell: treat as adrenal crisis now
Hypoglycaemia can be part of adrenal crisis. Give hydrocortisone without delay; do not wait for tests. No known adrenal insufficiency: go on to the next step.
- Adult: hydrocortisone 100 mg IV or IM now, alongside the glucose treatment below (do not delay glucose)
- Includes people on long-term glucocorticoids (steroid-dependent)
- Child: use a paediatric adrenal crisis dose
06Decision Alert and able to swallow safely?
Give nothing by mouth to a person who is not alert.
- If Yes
07Action Alert and can swallow: 15-20 g fast-acting glucose by mouth
Acarbose: pure glucose only (tablets or gel), not sugar. Automated insulin delivery (closed loop): usually 5-10 g.
- Glucose tablets 15-20 g (4-5 x 4 g tablets) or glucose gel 15 g
- Or about 200 mL fruit juice or regular (not diet) soft drink, or 3 teaspoons sugar or honey
- Low-potassium diet (CKD): use glucose tablets, not juice
- Do not use high-fat or high-protein food for the first treatment
08Action Recheck glucose 10-15 min after each treatment
Watch airway and conscious state while waiting.
09Decision Glucose 4.0 mmol/L or more and patient alert?
Both must be true.
- If Yes
10Action Recovered: give long-acting carbohydrate now
Give it within the next few minutes, as insulin or sulfonylurea can still be active.
- 20 g long-acting carbohydrate (for example 2 biscuits or 1 slice of bread) or the next meal
- After glucagon: give 40 g
- Nil by mouth: 10% glucose infusion 100 mL/h until eating or reviewed
- Do not omit the next due insulin dose; review the regimen
11Warning Sulfonylurea, long-acting insulin or overdose: hypo can recur for 24-36 h
Observe in hospital. Overdose or recurrent low glucose: call the Poisons Information Centre 13 11 26.
- Risk lasts up to 24-36 h after the last dose; longer in renal impairment
- Monitor glucose regularly for at least 24-48 h
- Recurs despite IV glucose: octreotide with toxicology advice (adult 50-100 mcg subcut every 6-8 h; off-label)
12Action All patients: find the cause and prevent recurrence
Level 2 or 3 event: review the treatment plan and de-intensify if needed.
- Missed meal, excess insulin or sulfonylurea dose, exercise, alcohol
- Renal or hepatic impairment, new interacting drug, adrenal insufficiency
- Prescribe glucagon if on insulin or at high risk; teach family or carers
- Give driving advice (Austroads fitness-to-drive standard)
13Decision Alert, eating, cause explained and no recurrence?
Sulfonylurea or long-acting insulin excess needs observation first.
- If Yes
14Outcome Yes: discharge with a plan and follow-up
Written hypo plan, glucagon, medicine changes and early GP or diabetes team review.
If No15Outcome No: admit for glucose monitoring
Recurrent, prolonged or unexplained hypoglycaemia, overdose, or sulfonylurea or long-acting insulin excess.
If No16Action Still low or not alert: repeat treatment
If glucose is now normal but the patient is still not alert, look for another cause (stroke, seizure, head injury, drugs, sepsis).
- Alert: repeat oral glucose; after 3 doses (30-45 min) give IV glucose or glucagon
- Not alert: repeat IV glucose (glucagon only if there is still no IV access)
- Recurrent low glucose or nil by mouth: 10% glucose infusion (for example 100 mL/h)
- Call for senior help
- Path rejoins step 08Shared downstream outcome
If No17Decision Not alert or cannot swallow: IV access available?
Nothing by mouth. Place on the side.
- If Yes
18Action IV access: give IV glucose now (adult)
Alcohol use or malnutrition: also give IV thiamine, but do not delay glucose.
- Preferred: 10% glucose 200 mL IV over about 15 min (20 g)
- Or 50% glucose 20-50 mL slow IV (about 3 mL/min) into a large vein; check the line is patent (leak causes tissue injury)
- Renal or heart failure: use the smallest volume
- Recheck glucose in 10 min
- Path rejoins step 08Shared downstream outcome
If No19Action No IV access: glucagon 1 mg IM (adult)
Not for phaeochromocytoma or insulinoma. Works poorly after fasting, alcohol, liver disease, adrenal insufficiency or sulfonylurea: get IV access for IV glucose.
- GlucaGen HypoKit 1 mg IM or subcut (adults and children 25 kg or more)
- Keep trying for IV access: a second glucagon dose is less likely to work
- Vomiting can occur: keep on the side
- Nasal glucagon 3 mg is an option where registered (not in Australia)
- Onset usually within 10-15 min; recheck glucose at 10 min
- Path rejoins step 08Shared downstream outcome
Guideline Source
ADA Standards of Care in Diabetes-2026, Section 6: Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult doses. Children: use the paediatric doses in the warning step and a paediatric guideline; neonates are not covered.
- In-hospital IV glucose doses follow JBDS-IP 2023 (UK) and the Australian glucose 50% PI; check your local hypoglycaemia protocol.
- Pregnancy, insulinoma and non-diabetic hypoglycaemia work-up are not covered.
- Sulfonylurea overdose needs toxicology advice; octreotide use is off-label.
Contraindicated Populations
neonates (use a neonatal hypoglycaemia guideline)
Applicable Regions
AUUSEUUK
AU: Treat glucose below 4.0 mmol/L. Glucagon: GlucaGen HypoKit 1 mg (only glucagon with a TGA PI). Poisons Information Centre 13 11 26.
EU: Check local glucagon formulations.
UK: JBDS-IP 2023 prefers 10% or 20% IV glucose over 50% glucose.
US: Nasal glucagon 3 mg and ready-to-use injectable glucagon or dasiglucagon are available and preferred for carers (ADA 6.16).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Hypoglycaemia Management in Adults with Diabetes?
The Hypoglycaemia Management in Adults with Diabetes is a emergency clinical algorithm for Endocrinology. It provides a structured decision tree to guide clinical decision-making, based on ADA Standards of Care in Diabetes-2026, Section 6: Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises.
What guideline is the Hypoglycaemia Management in Adults with Diabetes based on?
This algorithm is based on ADA Standards of Care in Diabetes-2026, Section 6: Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises (DOI: 10.2337/dc26-S006).
What are the limitations of the Hypoglycaemia Management in Adults with Diabetes?
Known limitations include: Adult doses. Children: use the paediatric doses in the warning step and a paediatric guideline; neonates are not covered.; In-hospital IV glucose doses follow JBDS-IP 2023 (UK) and the Australian glucose 50% PI; check your local hypoglycaemia protocol.; Pregnancy, insulinoma and non-diabetic hypoglycaemia work-up are not covered.; Sulfonylurea overdose needs toxicology advice; octreotide use is off-label.. Individual patient factors may require deviation from these recommendations.
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