What Are the ADA Standards of Care for Hypoglycemia & Glucagon Administration?

Every year, the American Diabetes Association (ADA) updates its “Standards of Care in Diabetes.” For 2024, the Standards of Care include important updates on several things, including (1) hypoglycemia prevention and management, (2) the role of CGMs in hypoglycemia management and (3) glucagon administration.

The title of Section 6 of the Standards of Care was changed to “Glycemic Goals and Hypoglycemia.” All hypoglycemia content throughout the clinical-practice recommendations was consolidated into this section.

How Should Blood-Sugar Levels Be Assessed?

According to Section 6.1, the ADA now recommends that patients with diabetes who experience frequent or severe hypoglycemia have their blood sugar checked every three months—rather than twice a year.

Sections 6.11a, 6.11b and 6.11c include recommendations for when and how healthcare practitioners should review a patient’s hypoglycemic history, awareness and risk.

The ADA recommends:

• History of hypoglycemia should be reviewed at every clinical encounter for all individuals at risk for hypoglycemia and evaluated as indicated.
• Clinicians should screen all individuals at risk for hypoglycemia for impaired hypoglycemia awareness.
• Clinicians should consider an individual’s risk for hypoglycemia when selecting diabetes medications and glycemic goals.

Gary Scheiner, MS, CDCES, is the owner and clinical director of Integrated Diabetes Services.

Scheiner has had type 1 diabetes since 1985 and has worked in a clinical setting since 1995. He also wrote the book “Think Like a Pancreas: A Practical Guide to Managing Diabetes with Insulin.”

Scheiner feels that clinicians checking blood sugar every three months, rather than twice a year, is not an effective way to analyze glucose management and identify problem areas that may require therapeutic changes.

“People who experience frequent or severe hypoglycemia should be using a continuous glucose monitor in order to track patterns and alert the user of pending hypoglycemia,” says Scheiner. “If CGM is not accessible, frequent fingerstick monitoring is essential for early detection and/or prevention of hypoglycemia—as well as overall glucose management.”

What Role Do CGMs Play for People at Risk for Hypoglycemia?

Speaking of CGMs, the American Diabetes Association believes that continuous glucose monitoring can be a useful tool for detecting and preventing hypoglycemia in many people with diabetes.

A new recommendation—Section 6.11d—was added to highlight the benefits of CGM “… for individuals at high risk for hypoglycemia..”

“There is clinical-trial evidence that CGM reduces rates of hypoglycemia in these populations,” writes the ADA.

It adds that CGM can reveal hypoglycemia and help identify patterns and precipitants of hypoglycemic events.

Furthermore, real-time CGM can provide alarms that can warn individuals of falling glucose so that they can intervene.

How Should Clinicians Educate Their Patients About Hypoglycemia?

Section 6.14 says all people taking insulin or at risk for hypoglycemia should receive structured education for hypoglycemia prevention and treatment.

This education should be ongoing for those who experience hypoglycemic events.

How Does Hypoglycemia Affect a Diabetes Treatment Plan?

Sections 6.15 and 6.16 were updated by the ADA to communicate how hypoglycemic events should inform modifications to the diabetes-treatment plan.

One or more bouts of level-2 or 3 hypoglycemia should trigger a reevaluation of a treatment plan, which may include deintensifying or replacing diabetes medications as needed.

• Level-2 hypoglycemia is when blood-sugar levels are lower than 54 mg/dL
• Level-3 hypoglycemia is when a person experiences episodes that require assistance from another person for recovery because they are confused or unconscious.

They also instruct doctors to utilize evidence-based initiatives to raise awareness of hypoglycemia.

According to Section 6.17, if compromised or decreasing cognition is discovered, the clinician, patient and caregiver should continue to examine cognitive function while being especially vigilant for hypoglycemia.

How Should Hypoglycemia Be Treated?

According to Section 6.12 of the Standards of Care, glucose is the preferred treatment for conscious people with glucose levels below 70 mg/dL.

However, any carbohydrate with glucose can be used.

If hypoglycemia persists 15 minutes after initial therapy, the ADA recommends repeating the treatment.

What are the ADA’s Standards of Care for Glucagon?

Glucagon is indicated for the treatment of hypoglycemia in people who are unable or unwilling to consume carbohydrates by mouth.

According to the ADA, glucagon should be provided to anyone using insulin or who is at high risk of hypoglycemia (Section 6.13).

“This includes people who only take basal insulin as well as those on multiple daily injections or an insulin pump,” says Scheiner. “It also includes those who take oral insulin secretagogues [sulfonylureas and meglitinides] that can cause hypoglycemia.”

Furthermore, the ADA Standards of Care state that anybody who assists someone who is sensitive to hypoglycemia should be informed of the placement of the glucagon and trained in its use.

These people include:

• Family
• Caregivers
• School personnel, and
• Others who provide support to these individuals.

Additional features of the ADA Standards of Care for glucagon:

• Glucagon preparations that do not have to be reconstituted are preferred.
• Clinicians should routinely review a person’s access to glucagon, as appropriate glucagon prescribing is very low in current practice.
• An individual does not need to be a healthcare professional to safely administer glucagon.
• Caregivers of people who use glucagon must be explicitly instructed not to administer insulin to people who are experiencing hypoglycemia.
• Although the physical and chemical stability of glucagon has improved with newer formulations, it is important to replace glucagon products when they reach their expiration date.
• To ensure safe and effective use, follow the product instructions for storing glucagon.

Glucagon brands are now available in easy-to-administer, prefilled automatic pens and nasal spray.

This content was made possible by Xeris Pharmaceuticals®—the maker of Gvoke HypoPen®—an active partner of Beyond Type 1.

Beyond Type 1 maintains editorial control over its content.