Severe Hypoglycemia and Hyperglycemia from Diabetes Medications: Emergency Care

When your blood sugar drops too low or spikes too high, it’s not just inconvenient-it’s life-threatening. For people on insulin or certain diabetes medications, severe hypoglycemia and severe hyperglycemia can strike without warning. And if you don’t know how to respond, the consequences can be fatal.

What Counts as a Severe Emergency?

Severe hypoglycemia isn’t just feeling shaky or sweaty. It’s when your blood sugar falls below 54 mg/dL (3.0 mmol/L) and you’re too confused, weak, or unconscious to treat yourself. You need someone else to help. This often happens with insulin, sulfonylureas, or meglitinides-medications that force your body to dump glucose out of your bloodstream. Even a small mistake-like skipping a meal after taking insulin-can trigger it.

Severe hyperglycemia is different. It’s not just high numbers. It’s when your body starts breaking down fat for energy because it can’t use glucose. That creates toxic acids called ketones. Two dangerous conditions can result: diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). DKA usually hits people with type 1 diabetes, with blood sugar over 250 mg/dL, ketones in the blood, and acid in the bloodstream (pH below 7.3). HHS is more common in type 2 diabetes, with blood sugar soaring past 600 mg/dL, extreme dehydration, and no major ketones. Both can lead to coma or death if not treated fast.

Glucagon: The Lifesaver You Might Not Know How to Use

If someone is unconscious or having a seizure from low blood sugar, you don’t give them food or juice. You give them glucagon. It’s a hormone that tells the liver to dump stored sugar into the blood. For decades, glucagon came as a powder you had to mix with liquid, then inject. Most people never learned how. A 2021 study found only 42% of caregivers could successfully use the old kit.

Now, there are easier options. Baqsimi is a nasal spray-just insert it into one nostril and press. Gvoke is a pre-filled autoinjector like an EpiPen-you press it against the thigh and hold for five seconds. Both work in under 15 minutes. In clinical trials, nasal glucagon worked in 93% of cases. No mixing. No needles. No panic.

But here’s the problem: most people still don’t have it. A 2022 survey found only 41% of type 1 diabetes patients always carried glucagon. Why? Fear. Confusion. They think they’ll use it wrong. Or they don’t know it’s covered by insurance. Some plans still make it harder to get the newer versions than the old kit. But if you’re on insulin, you need one-now. The American Diabetes Association says every insulin user should have glucagon prescribed and accessible at all times.

What to Do During a Hyperglycemic Emergency

If someone has high blood sugar and is vomiting, breathing fast, smells fruity, or is confused, don’t just give more insulin. That’s a deadly mistake. First, check for ketones with a blood or urine test. If ketones are above 1.5 mmol/L, this is an emergency. Call 911 or go to the ER.

In the hospital, treatment is three-part: fluids, electrolytes, and insulin. They start with IV saline-1 to 2 liters in the first hour-to rehydrate the body. Then they replace potassium, which gets washed out by high sugar. Finally, they give insulin through an IV drip, not a shot. The dose is precise: 0.1 units per kg of body weight per hour. Too much insulin too fast can crash potassium levels and cause heart problems.

For mild DKA (pH above 7.0), some doctors now use fast-acting insulin shots under the skin. But if the person is in a coma or pH is below 7.0, IV insulin is non-negotiable. The key is speed. Untreated DKA kills 70% of people. With treatment, mortality drops to 1-5%.

Common Mistakes That Cost Lives

Too many emergencies go wrong because of simple errors. One of the worst? Trying to give someone juice or a snack while they’re unconscious. That can cause choking or aspiration pneumonia. Never put anything in the mouth of an unconscious person. Ever.

Another mistake: waiting too long to seek help. A T1D Exchange survey found 58% of DKA cases happened because people waited over 12 hours after symptoms started. They thought it was just the flu. Or they didn’t know ketones were dangerous. Early signs of DKA? Dry mouth, frequent urination, nausea, fruity breath, fatigue. Don’t wait for vomiting or confusion.

And then there’s the insulin-overuse trap. Some people see high blood sugar and think, “I need more insulin.” But if ketones are present, the body can’t use insulin properly yet. Giving more insulin without fluids and electrolytes can make things worse. That’s why testing for ketones is mandatory before giving any extra insulin during a high-blood-sugar crisis.

Preparing for the Worst

Your emergency kit should be simple and ready:

• One ready-to-use glucagon (Baqsimi or Gvoke)
• Glucose tablets (15g portions-4 tablets of 4g each)
• Blood ketone meter and test strips
• Emergency contact list with doctor and family numbers
• Medical ID bracelet or card

Practice using the glucagon device every three months. Use a training kit (they come free with most prescriptions). Families, teachers, coworkers-anyone who might be with you during an emergency-should know where it is and how to use it.

Schools and workplaces often refuse to help because they’re not trained. A mother on Reddit shared how her child’s school nurse refused to give glucagon because she’d never been trained. The child ended up in the ER. Training programs like ADA’s “Hypoglycemia Uncovered” show that a 30-minute video increases successful administration from 32% to 89%. Demand training. Don’t assume someone else will know what to do.

What’s Changing Now?

The biggest breakthrough in 2023 was the FDA approval of the first dual-hormone artificial pancreas-the Beta Bionics iLet. It automatically releases glucagon when it predicts a low. In trials, it cut severe hypoglycemia by 72%. But it’s only available at 12 U.S. centers right now. It’s expensive. Insurance coverage is limited.

New glucagon analogs like dasiglucagon are in phase 3 trials. They work in under two minutes. FDA approval could come by late 2024. And companies like Eli Lilly are now bundling glucagon prescriptions with mobile apps that walk you through administration step by step.

But progress isn’t equal. Black and Hispanic patients are 2.3 times more likely to be hospitalized for severe hypoglycemia than white patients. Why? Less access to medications, fewer prescriptions, and less education. Emergency care isn’t just about medicine-it’s about equity.

What You Must Do Today

If you or someone you love uses insulin:

1. Get a prescription for ready-to-use glucagon-Baqsimi or Gvoke.
2. Keep it with you at all times-not in the glove compartment, not in the fridge at home.
3. Teach at least two people how to use it.
4. Test for ketones if blood sugar is over 250 mg/dL and you feel sick.
5. Call 911 if you’re confused, vomiting, or breathing fast.

This isn’t about being careful. It’s about being prepared. One minute of training could save a life. Don’t wait for an emergency to learn what to do.

Next Steps and Troubleshooting

If you’ve never used glucagon before, start here:

• Ask your doctor for a prescription for Baqsimi or Gvoke-don’t settle for the old kit unless you have no other option.
• Request a training device from the manufacturer (they’re free).
• Practice with a family member or friend once a month.
• Keep glucagon in your bag, car, or workplace-not just at home.
• Set phone reminders to check expiration dates every 3 months.

If you’re caring for someone with diabetes:

• Know where their emergency kit is.
• Know how to call 911 and what to say: “This is a diabetic emergency-possible severe hypoglycemia or DKA.”
• Don’t wait for them to wake up before acting.

The best emergency plan is the one you’ve practiced. Don’t wait for a crisis to learn what to do. Learn now. Prepare now. Save a life.