Hypoglycaemia (Severe, Inpatient)Emergency

Type 2 diabetes on gliclazide and insulin, eGFR 35; found sweaty and confused at 4 am; capillary glucose 42 mg/dL

• Seizure or coma
• Recurrence after initial treatment
• Hypoglycaemia in a non-diabetic
• Hypotension or shock (sepsis, adrenal crisis)

• Stroke or seizure mimicking neuroglycopenia
• Alcohol intoxication
• Adrenal insufficiency
• Liver failure
• Insulinoma (non-diabetic)
• Factitious insulin/sulfonylurea use

• Admit: Sulfonylurea or long-acting insulin cause, recurrent episodes, not back to normal, no one at home, CKD, intentional overdose
• ICU: Persistent coma, seizures, needing concentrated dextrose via a central line

• Sulfonylureas (especially glibenclamide) and insulin cause most hypoglycaemia; CKD, old age, poor intake and sepsis are the usual triggers.
• Hypoglycaemia unawareness after repeated episodes — raise targets for 2–3 weeks to restore warning symptoms.
• Non-diabetic adult hypoglycaemia: document Whipple triad and draw the critical sample during the episode (insulinoma, adrenal insufficiency, liver failure, drugs, alcohol, sepsis).

• Delay glucose to take blood tests
• Send home a patient with sulfonylurea hypoglycaemia after one normal reading
• Give 50% dextrose into a small peripheral vein if a larger one or 10% is available (thrombophlebitis, extravasation injury)
• Omit the next insulin dose altogether in type 1 diabetes — adjust it instead

• Discharging after sulfonylurea hypoglycaemia
• Not finding the cause
• Over-correcting with repeated 50% dextrose
• Leaving the insulin dose unchanged

Admit for sulfonylurea or long-acting insulin, recurrence or no support; diabetes team to redesign the regimen.