Diabetes Emergencies

100 | Management of type 2 diabetes: A handbook for general practice
Managing glycaemic emergencies
Hypoglycaemia and hyperglycaemia-related emergency presentations such as diabetic

ketoacidosis (DKA) and hyperglycaemic hyperosmolar states (HHS) form the basis of
this section. Refer to ‘Appendix 3. Detailed information on glycaemic emergencies’
for more information.
Recommendations
Recommendation Reference Grade*
Individuals at risk for hypoglycaemia should be asked about 1 C

symptomatic and asymptomatic hypoglycaemia at each encounter
American Diabetes Association, 2019
Glycaemic goals for some older adults might reasonably be relaxed 1 C

as part of individualised care, but hyperglycaemia leading to
American Diabetes Association, 2019
symptoms or risk of acute hyperglycaemia complications should be
avoided in all patients
*Refer to ‘Explanation and source of recommendations’ for explanations of the levels and grades of evidence.
Clinical context
In patients with type 2 diabetes, very high and low glycaemic states can occur. Both
have significant impacts and implications. Patients should be well educated and informed
about both states, and an active management plan should be developed.
Hypoglycaemia
Hypoglycaemia is defined as a blood glucose level (BGL) of ≤3.9 mmol/L and/or to a level
that causes neurogenic and neuroglycopenic symptoms and signs.2,3 Rarely, a person
who has normal BGLs can display symptoms (known as ‘pseudo-hypoglycaemia’);
this might occur, for example, when someone has experienced persistent, prolonged
hyperglycaemia and the elevated glucose levels have become normalised.4,5
Hypoglycaemia in people with type 2 diabetes is common,5 and its impact must not be
underestimated, particularly in patients where the morbidity of hypoglycaemia poses
particular problems and symptoms may be unrecognised. Higher risk patients include
older people, people with renal impairment, people with poor cognitive function and those
with low health literacy.6,7
Symptoms of hypoglycaemia vary between people, and include:
• adrenaline activation symptoms, including pale skin, sweating, shaking, palpitations
and a feeling of anxiety or dizziness
• neuroglycopenic symptoms, including hunger, change in intellectual processing,
confusion and changes in behaviour (eg irritability), paraesthesia, then coma and seizures.
Hypoglycaemia is more common in people taking insulin, alone or in combination with
other glucose-lowering medications; it can also occur with sulfonylurea therapy. Other
causative factors are insufficient carbohydrate intake, renal impairment and excessive
alcohol ingestion, and change in physical activity.
Managing glycaemic emergencies | 101
Asymptomatic hypoglycaemia (or biochemical hypoglycaemia) occurs when

someone’s BGLs are low (≤3.9 mmol/L), but the typical symptoms of hypoglycaemia
are not present.4
Severe hypoglycaemia is defined as signs of hypoglycaemia whereby the person
requires the assistance of another person to actively administer corrective action such
as carbohydrate, and/or glucagon and glucose infusion. A BGL of <3.0 mmol/L may
carry a risk for severe hypoglycaemia.4
Impaired hypoglycaemia awareness occurs where the pathophysiologic symptoms
that arise in response to mild or severe hypoglycaemia (refer to Appendix 3) are reduced
or absent and the patient loses the ability to detect the early symptoms of hypoglycaemia.
In such cases, symptoms may be recognised by other family members and carers before
the patient, and the patient is more likely to have episodes of severe hypoglycaemia.
The development of impaired hypoglycaemia awareness is associated with recurrent
episodes of hypoglycaemia and longer duration of type 2 diabetes. Patients with
impaired hypoglycaemia awareness may benefit from options such as review of
pharmacological and hypoglycaemia management, and continuous or ambulatory
glucose monitoring, as this condition may be reversible.
Hyperglycaemia
Hyperglycaemic states include emergencies such as HHS (formerly known as
hyperosmolar non-ketotic coma [HONC]) and DKA. Signs of hyperglycaemic states include:
• severe dehydration with polyuria and polydipsia
• abdominal pain, nausea and vomiting
• altered consciousness
• shock
• ketotic breath, in patients with DKA.
These conditions occur due to very unstable glucose levels, implying diabetes
management issues or underlying causes such as infection or myocardial infarction,
which require concomitant management. DKA is rare in people with type 2 diabetes
relative to type 1 diabetes, but it has increased with sodium glucose co-transporter 2
(SGLT2) inhibitor use and is important to recognise (Appendix 3).
Hyperglycaemic thresholds related to acute elevations of venous or self-monitoring of
blood glucose results >15 mmol/L on two subsequent occasions, two hours apart, with
clinical symptoms of metabolic disturbance, should be considered a hyperglycaemic
emergency and require assessment and intervention; refer below or to The Royal
Australian College of General Practitioners (RACGP) and Australian Diabetes Society (ADS)
clinical position statement Emergency management of hyperglycaemia in primary care.
More information about management of hypoglycaemia and hyperglycaemia can be
found in Appendix 3. Sick day management of hyperglycaemia is discussed in the
section ‘Managing risks and other impacts of type 2 diabetes’.
In practice
All patients with type 2 diabetes on insulin and/or sulfonylureas, and their families
or carers, should be informed about the risk factors, signs and symptoms of
hypoglycaemia and hyperglycaemia, and actions to be taken.
102 | Management of type 2 diabetes: A handbook for general practice
If a patient has experienced severe hypoglycaemia, it may help to identify a carer who
can be trained in glucagon administration to assist with early intervention and avoid
recurrence. The Australian Diabetes Educators Association sick day management
guidelines may be used to assist practical patient management.
You may also refer to the National Diabetes Services Scheme and Diabetes Australia’s
advice on sick day management for people with type 2 diabetes.
Hypoglycaemia: Practice points

• People can experience episodes of hypoglycaemia at any glycated haemoglobin
(HbA1c) level, even if it is at target. Regular BGL monitoring should be used to
monitor for hypoglycaemia. Real-time continuous glucose monitoring may help
reduce risks of hypoglycaemia, but the cost and availability of this technology and its
use in at-risk populations such as older people needs further evaluation.8
• De-prescribing of medication may be needed to manage risk of hypoglycaemia.
• Patients are often not forthcoming about symptoms of hypoglycaemia. GPs should
therefore ask appropriate questions to detect hypoglycaemia (adrenergic and
neuroglycopenic symptoms) to help with interpretation of BGLs. This is particularly
important for older people and those with renal dysfunction.
• All people with diabetes with impaired hypoglycaemic awareness should be referred to
an endocrinologist or specialist physician with an interest in diabetes for assessment.
Managing hyperglycaemic emergencies: General advice

• Look for an underlying cause – for example, sepsis, myocardial infarction.
• Post-event: review medications, dietary intake and hyperglycaemic and sick day
management.
For more detailed information on DKA and HHS, refer to:
• the RACGP and ADS position statement on Emergency management of
hyperglycaemia in primary care
• the ADS alert regarding periprocedural DKA with SGLT2 inhibitor use
• Appendix 3 for detailed information on glycaemic emergencies.
References
1. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care
2019;42 Suppl:S1–S194.
2. Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018
clinical practice guidelines for the prevention and management of diabetes in Canada.
Can J Diabetes 2018;42 Suppl:S1–325.
3. Balijepalli C, Druyts E, Siliman G, Joffres M, Thorlund K, Mills EJ. Hypoglycemia: A review of
definitions used in clinical trials evaluating antihyperglycemic drugs for diabetes. Clin Epidemiol
2017;9:291–96.
4. Seaquist E, Anderson J, Childs B. Hypoglycemia and diabetes: A report of a workgroup of the
American Diabetes Association and the Endocrine Society. Diabetes Care 2013;36:1384–95.
5. Morales J, Schneider D. Hypoglycaemia. Am J Med 2014;127 Suppl:S17–S24.
6. American Diabetes Association. Standards of medical care in diabetes: 6. Glycemic targets.
Diabetes Care 2019;42 Suppl:S61–S70.
7. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: Physician communication with
diabetic patients who have low health literacy. Arch Intern Med 2003;163(1):83–90.
8. Rodard D. Continuous glucose monitoring: a review of recent studies demonstrating improved
glycemic outcomes. Diabetes Technol Ther 2017;19 Suppl:S25–S37.
Managing glycaemic emergencies | 103
Disclaimer
The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general
nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the
subject matter. It is no substitute for individual inquiry. Compliance with any recommendations does not guarantee discharge of
the duty of care owed to patients. The RACGP and its employees and agents have no liability (including for negligence) to any
users of the information contained in this publication.
© The Royal Australian College of General Practitioners 2020
This resource is provided under licence by the RACGP. Full terms are available at www.racgp.org.au/usage/licence
We acknowledge the Traditional Custodians of the lands and seas on which we work and live, and pay our respects to Elders,
past, present and future.
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100 | Management of type 2 diabetes: A handbook for general practice

Managing glycaemic emergencies

Hypoglycaemia and hyperglycaemia-related emergency presentations such as diabetic

Recommendation Reference Grade*

Individuals at risk for hypoglycaemia should be asked about 1 C

Glycaemic goals for some older adults might reasonably be relaxed 1 C

Asymptomatic hypoglycaemia (or biochemical hypoglycaemia) occurs when

Hypoglycaemia: Practice points

Managing hyperglycaemic emergencies: General advice

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