SCREENING FOR PRE-DIABETES AND DIABETES IN UNDIAGNOSED ADULTS

SCREENING FOR PRE-DIABETES AND DIABETES IN UNDIAGNOSED ADULTS (over 21)

Screening is for asymptomatic individuals.  If a person has symptoms (i.e. polyuria, polydipsia, blurred vision, weakness, lethargy, weight loss, and sometimes polyphagia), referral to a physician may be necessary.  It is the clinician’s discretion as to whether to perform a blood glucose test and, if positive, refer to physician, or to refer to the physician for testing. 

1. Screening should be considered “in all adults who are overweight or obese (BMI >25 kg/m^2*)” (Diabetes Care, Vol. 34, Supp. 1, Jan. 11, p. S13) and have one or more of the following risk factors (See PHPR Physical Assessment/Vital Signs Section for BMI chart):

• Have a first-degree relative with diabetes
• Are members of a high-risk ethnic population (i.e., African-American, Hispanic/ Latino, Native American, Asian-American, Pacific Islander)
• Have delivered a baby weighing >9 lbs or have been diagnosed with GDM
• Are hypertensive (> 140/90 mmHg or on therapy for hypertension)
• Have an HDL cholesterol level < 35 mg/dl (0.90 mmol/l) and/or a triglyceride level > 250 mg/dl (2.82 mmol/l)
• On previous testing, had Impaired Glucose Tolerance (IGT-2-h 75 g OGTT values of 140 mg/dl to 199 mg/dl)) or Impaired Fasting Glucose (IFG-FPG levels of 100 mg/dl to 125 mg/dl) or A1C of 5.7-6.4%.  IGT and IFG are now called Pre-diabetes.
• Are habitually physically inactive
• Have polycystic ovary syndrome (PCOS) or other clinical condition associated with insulin resistance (e.g., acanthosis nigricans - a skin disorder characterized by dark, thick, velvety skin found especially in folds of skin in the axilla, the groin, and on the back of the neck, severe obesity)
• Have a history of cardiovascular disease

2.      In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at

            age 45 years

3.      If results are normal (FPG < 100, 2 hour postprandial PG < 140, A1C < 5.7%), testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

4.      Either A1C, FPG or 2 hr 75 g OGTT are appropriate to test for diabetes or to assess risk of future diabetes. 

5.      Monitoring for the development of diabetes in those with pre-diabetes should be      performed every year.

6.      For those identified with increased risk for future diabetes, identify and, if appropriate,     treat other CVD risk factors.

            * In some Asian populations, the proportion of people at high risk of type 2 diabetes and                    cardiovascular disease is significant at BMIs of >23 kg/m².  (Diabetes Care, Vol.31,                             Supplement 1, January 2008, p S62)

        

Note:  Clinical judgment should be used to test for diabetes in high-risk patients who do not meet these criteria.

Testing for Undiagnosed Type 2 Diabetes in Children/Adolescents (under 21):

·         Criteria**

Overweight or at risk for overweight: (According to CDC, BMI >85^th percentile to <95^th percentile is considered at risk for overweight and >95^th percentile is considered overweight.)  See MCH 1–4 (Growth Charts) for BMI

Plus any two of the following risk factors:

o   Family history of type 2 diabetes in first or second-degree relative

o   Race/ethnicity (Native American, African-American, Hispanic/Latino, Asian-American, Pacific Islander)

o   Signs of insulin resistance or conditions associated with insulin resistance such as acanthosis nigricans (a skin disorder characterized by dark, thick, velvety skin found especially in folds of skin in the axilla, the groin, and on the back of the neck), hypertension, dyslipidemia, polycystic ovary syndrome (PCOS), or small-for-gestational-age birth weight.

o   Maternal history of diabetes or gestational diabetes mellitus (GDM) during the child’s gestation.

·         Age to begin testing**: age 10 years or at onset of puberty, if puberty occurs at a younger age

·         Testing Frequency: every 3 years

** Clinical judgment should be used to test for diabetes in high-risk patients who do not meet these criteria.

 

 

 

 

 

MINIMAL REQUIREMENTS FOR A PRE-DIABETES OR DIABETES SCREENING VISIT

AGES 21 AND OLDER

Assessment	Initial Visit	Subsequent Visit
Comprehensive health history to include ·         Age/race ·         First degree relative with diabetes* ·         Signs of, or conditions associated with, insulin resistance: hypertension (>140/90) or on therapy for hypertension, dyslipidemia, polycystic ovary syndrome, acanthosis nigricans, severe obesity) ·         Signs and symptoms of diabetes ·         Previous impaired glucose metabolism ·         Activity level ·         Delivered a baby >9 lbs or have been diagnosed with GDM ·         History of cardiovascular disease	CH 13 or H&P-13: Required (Update every 3 years)	CH 14 or H&P- 14:  At least annually
Physical Examination to include ·         Documentation of general appearance and mental status ·         Height/weight/BMI ·         Blood pressure	X	X
Laboratory ·         Blood glucose (see Lab Section for values)	X	Repeat every 3 years if the initial screening test was normal or more often depending on risk factors or if symptoms develop. (Monitor annually for those with pre-diabetes.)
·         Cholesterol screening (see Lab Section for values)	S	Most adult patients, measure fasting lipid profile annually.  Adults with low-risk lipid values (LDL <100, HDL >50, triglycerides <150) may be repeated every 2 years.
Counseling ·         Risk reduction counseling (including CVD risk factors): Resources:  Your Game Plan for Preventing Type 2 Diabetes, Get Real! You Don’t Have to Knock Yourself Out to Prevent Diabetes, and other resources for high-risk populations from NDEP online, and The Power of Prevention (KDPCP).  ·         Patients with pre-diabetes should be referred to an effective ongoing support program for weight loss and physical activity, if available.  (Suggested 5-10% loss of body weight & increasing physical activity to at least 150 min/week of moderate activity such as walking.  Follow-up counseling is important for success.)  ·         Anticipatory guidance (ACH-10 or 40)	X	X
·         Refer for Medical Nutrition Therapy	S	S
Documentation of referral and return clinic appointment, if applicable	X	X

S = Clinician discretion      X = Required        

* = First-degree relative: mother, father, sibling, or child

REFERENCE: American Diabetes Association: Clinical Practice Recommendations 2011, http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.pdf+html

DIABETES MELLITUS INITIAL SERVICE*

Condition	Initial Assessment	Initial Plan/Intervention
Diabetes Mellitus is a chronic disorder in which the body is unable to use food properly.  Insulin is not available in the body or does not work properly resulting in elevated blood glucose levels and other metabolic disturbances.   Chronic high blood sugar is associated with severe kidney, eye, and nerve complications as well as peripheral, cerebral, cardiovascular disease, and dental disease.	1.   Health History (Use CH 13 or H&P-13).  Include the following information: a)     Symptoms b)    Nutritional status, eating patterns, weight history.  Growth and development in children and adolescents (Use MCH 1–4) c)     Frequency, severity, and treatment of hypoglycemia d)    History of ketoacidosis and diabetes related hospitalizations e)     Chronic complications, symptoms, treatment and most recent date (USE CH 13, H&P-13, or CH3A): 1.     Dilated eye exam 2.     Blood lipid levels 3.     Urine check for micro-albuminuria and protein and serum creatinine for the estimation of  GFR 4.     Dental visit 5.     EKG 6.     Last foot exam (including monofilament) 7.     Skin exam (Ex: insulin injection sites) f)     Immunization status (include flu/pneumococcal) 2.   Additional Information (Use CH 13, H&P-13, or CH3A) a)     Self-management skills.  Examples include: Monitoring? How often? Correct Usage? Exercise? How much? Daily foot inspection?, Management plan for sick days?, Wears diabetes identification?, Any previous diabetes education? Where? When? b)    Glycemic control (A1C records and home blood glucose monitoring diary) c)     Gestational history (include wt of biggest infant) and plans for pregnancy and birth control 3.   Physical Assessment (Use CH 12) a)     Ht/Wt/BMI (Growth/Development in children) b)    B/P 4.   Lab Tests (Use CH 12) a)     Blood glucose b)    Urine test for ketones if blood glucose is greater than 300 mg/dl c)     Annual fasting blood lipid profile** (unless patient meets the criteria for low risk as defined for Lipid Profile, Low Risk Criteria)	Collaborate with patient/other members of health care team to develop a plan of care to address identified needs of diabetes education: Plan of Care to include: a)      Provide/initiate, or refer for, diabetes education (based on the Goals for Diabetes Self-Management Education/Training in this section) (preferably group diabetes self-management education/training classes/local diabetes support group, if available) b)      Schedule for Medical Nutrition Therapy c)      Assist with identification of self- management behavior goals and encourage development of self-management skills including home blood glucose monitoring (encourage patient to bring record of home blood glucose values to each clinic visit if testing) d)      Educate according to identified needs for: 1.     Annual dilated eye exam 2.     Family planning for women of reproductive age 3.     Tobacco cessation/support program       Refer to quit line -1-800-QUIT NOW       4.     Preventive dental exam/care every 6 months 5.     Foot specialist/physician 6.     Flu/pneumococcal vaccinations 7.     Lab tests (A1C, fasting lipid profile, microalbuminuria/protein, serum creatinine for the estimation of glomerular filtration rate [GFR] in adults) 8.     EKG 9.     Mental health professional, if needed e)      Determine frequency follow-up necessary and schedule return appointment f)       Communicate by phone or in writing with primary care provider concerning patient progress and follow-up recommendations.

* For individuals already diagnosed with diabetes

** No need to do if previously performed at another health care setting

GUIDELINES FOR DIABETES MELLITUS

FOLLOW-UP SERVICE

Need Condition	Follow-Up Assessment	Follow-Up Plan/Intervention
Diabetes mellitus is a chronic disorder in which the body is unable to use food properly.  Insulin is not available in the body or does not work properly resulting in elevated blood glucose levels and other metabolic disturbances.  Chronic high blood sugar is associated with severe kidney, eye, and nerve complications as well as peripheral, cerebral, cardiovascular disease, and dental disease.	1.     Update health history (Use CH 14, H&P-14, or CH3A) including: Determine glycemic control (Review home blood glucose values and A1C history, if available.) 2.    Physical Assessment (CH 12) a.    Weight b.    B/P 3.    Lab Tests (CH 12) a.    Blood glucose b.    U/A for ketones if blood glucose > 300 mg/dl	1.    Evaluate progress toward and update plan of care.  2.    Schedule return appointment as appropriate.

Guidelines for Clinician Notification/Referral (for patient with a diagnosis of diabetes)
Test/Exam	Significant Findings	Action*
Blood Glucose** Fasting-no caloric intake for at least 8 h. Random (Casual)-any time of day without regard to time since last meal.	1.   Fasting >130 mg/dl or random (casual) >180 mg/dl 2.   Fasting or random (casual) >300 mg/dl	1.   Notify clinician by phone or in writing 2.   Notify clinician immediately
Urine	Ketones present in any amount	Notify clinician immediately
Blood Pressure	>130/80 mm/Hg	See guidelines in Physical Assessment/Vital Signs Section
Lipid Profile* *Note:  Aggressive therapy of dyslipidemia in a person with diabetes may reduce the risk of CVD.	Low Risk Criteria: 1.   Triglyceride <150 and 2.   LDL cholesterol <100 and 3.   HDL cholesterol >50 Positive: 1.   Triglyceride >150 2.   LDL cholesterol >100 3.   HDL Cholesterol <40 (men), < 50 (women)                                                                                                                                                 Target Lipid Levels for adults with diabetes: 1.  Triglyceride <150 2.  LDL cholesterol <100 3.  HDL cholesterol >40 (men), >50 (women)	Low Risk: 1.   Repeat screen every 2 years or clinician’s discretion 2.   Provide preventive counseling Positive: 1.   Refer for MNT 2.   Refer for medical evaluation 3.   Identify with patient modifiable risk factors, including need for improved glycemic control 4.   Discuss lifestyle changes individualized to patient needs and modifiable risk factors 5.   Document referral and return appointments, as appropriate 6.   May be re-evaluated  in 2–3 months or clinician’s discretion

*Based on current management plan and clinical judgment, it may be appropriate to adjust action.

**Note: meter must yield a plasma equivalent value if capillary specimen performed.

Goals for Diabetes Self-Management Education/Training	Patient Education Resources	Professional Resources
DSME/T is based on the patient’s identified educational need(s) which may be addressed in the clinic setting unless/until patient can be referred to available group DSME/T classes/local diabetes support group. Behavior Change/Goal Setting Patient will set short-term behavior change goal(s) that are realistic and measurable for each section.  The goal(s) can be recorded on the CH13, H&P-13, or CH3A. Overview of Diabetes/Diabetes Disease Process 1.     Explain diabetes and how it is treated in own words. Healthy Eating/Nutrition 1.     State the relationship of food and meals to medication, physical activity and blood glucose levels. 2.     State that food is important in the control of blood glucose and lipid levels. 3.     Demonstrate how to use the Diabetes Food Pyramid to guide food choices and amounts. 4.     List the types and amounts of foods to be included in his/her meal plan. 5.     State the importance of limiting intake of fats and sweets. 6.     State importance of reading labels and demonstrate basic understanding of a label. 7.     State the importance of maintaining a healthy weight to manage diabetes. 8.     If taking insulin, or oral diabetes medication, state the importance of regular meals and snacks as recommended. 9.     State factors that influence eating decisions (i.e. culture, peers, money, religion, stress, emotions) Patient to develop a behavior change goal: Being Active/Physical Activity 1.     State the value of regular activity in blood glucose control, overall health, and weight and diabetes management. 2.     State the importance of a medical check-up, EKG, and clinician approval before starting a regular exercise program. 3.     State that hypoglycemia can result from exercise when certain medications are used. 4.     State the reason for carrying a carbohydrate snack and list examples. 5.     Explain the value of monitoring blood glucose levels before and after exercise. 6.     Identify situations when exercise is not appropriate, e.g., sick days or when fasting glucose levels are over 250 and ketones are present, and use caution if glucose levels are over 300 and no ketones are present. Patient to develop a behavior change goal: Taking Medication (if applicable) 1.     State name, dose, frequency of medications. 2.     State action and possible side effects of medications. 3.     State the time of onset, peak, and duration of the insulin or other injectable medication prescribed. 4.     Explain the relationship of peak action of medications to food intake. 5.     If taking insulin, demonstrate the ability to draw up, mix and inject needles correctly. 6.     If taking other injectable medication, demonstrate the ability to draw up and inject correctly. 7.     If taking insulin or other injectable medication, describe the care, storage, and disposal of medication, needles and syringes (guidelines in your area). 8.     Identify appropriate medication regimen aids. Patient to develop a behavior change goal: Problem Solving of Acute Complications 1.     If treatment includes oral agents or insulin: a.   List possible signs, symptoms, causes and prevention of hypoglycemia. b.   State how to treat hypoglycemia, and the need to carry a carbohydrate source (usually 10–15 grams) at all times – glucose tablets/gel or skim milk/lactose are necessary when taking (carbohydrate/starch blockers) such as Precose (acarbose) or Glyset (miglitol). 2.     List the possible signs, symptoms, causes, treatment, and prevention of hyperglycemia. 3.     State sick day guidelines including how and what medication to take during illness. 4.     State when and how to contact clinician in case of illness, hypoglycemia or hyperglycemia. 5.     State the need to carry and wear diabetes identification. 6.     Describe appropriate safety concerns and course of action to prevent injury. Patient to develop a behavior change goal: Self Monitoring of Blood Glucose and Use of Results 1.      State the importance of monitoring blood glucose in the reduction of acute complications of diabetes. 2.      State that SMBG is used to check glucose levels at home between clinic visits to learn how food, activity and medication are affecting blood glucose levels. 3.      If applicable, demonstrate the ability to perform blood glucose testing. 4.      State that urine should be tested for ketones if blood glucose level is >300 mg/dl. 5.      Describe appropriate use of blood glucose results to improve glycemic control and proper disposal of sharps. Patient to develop a behavior change goal:   Reducing Risks of Diabetes Complications 1.       List long-term complications associated with uncontrolled diabetes. 2.       Identify A1C number, frequency of A1C testing, and importance of blood glucose control for prevention of complications. 3.       State the need for B/P control as well as tobacco cessation.  If smoke, state quit line # - 1-800-QUIT NOW. 4.       List the recommendations for daily foot care and demonstrate foot inspection, including use of a monofilament. 5.       State the need for good personal hygiene and skin care. 6.       Describe the components of daily dental and mouth care. 7.       State the need for annual dilated eye exam, kidney tests, and blood lipid tests. 8.       Women of reproductive age:  Describe importance of good blood glucose control prior to conception and during pregnancy. 9.       State importance of flu/pneumonia vaccination in prevention of illness. Patient to develop a behavior change goal: Living with Diabetes/Healthy Coping 1.       Explore coping techniques that can be used to assist in dealing with individual needs to improve quality of life. 2.       Identify alternative courses of action for dealing with individual issues. 3.       Develop strategies to include others in the plan of care. Patient to develop a behavior change goal: Community Resources/Use of Health Care Systems 1.      List community resources available for diabetes care, education and support. 2.      List community resources available for help with other social and economic problems. 3.      State the need for regular or ongoing medical care, including follow-up and ongoing self-management education. 4.      Describe how to obtain emergency medical care.	Materials currently available in the Pamphlet Library, Frankfort, at 502-227-9529 or from the KY Diabetes Prevention and Control Program (502-564-7996) are published by KDPCP, Krames, or the National Diabetes Education Program (NDEP).      (All NDEP materials are also available on-line at www.ndep.nih.gov or by calling 1-800-438-5383.  Most are available in Spanish.  Some are also available in other languages.) ·     Diabetes Basics* (KDPCP, Eng & Sp) ·     Living Well with Diabetes Workbook (Krames) Recommended for DSME/T classes only. ·     Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·     Four Steps to Control Your Diabetes For Life (NDEP) ·      Diabetes Basics (KDPCP, Eng & Sp) ·     Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·      Eating Well with Diabetes (Krames, Eng & Sp) ·     Nutrition Basics Eating Healthy with Diabetes* (KDPCP) ·     Diabetes Basics (KDPCP, Eng & Sp) ·     Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·     Diabetes Basics (KDPCP, Eng & Sp) ·     Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·     Diabetes Basics (KDPCP, Eng & Sp) ·     Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·         Diabetes Basics (KDPCP, Eng & Sp) ·         Living Well with Diabetes Fast Guide (Krames, Eng & Sp) ·         If You Have Diabetes, Know Your Blood Sugar         Numbers (NDEP) ·         NDEP’s The Power to Control Diabetes Is In Your Hands (seniors)(online) ·         Safe Options for Home Needle Disposal http://waste.ky.gov/RLA/Documents/Factsheetneedles010711.pdf ·         If You Have Diabetes, Protect Your Eyesight (KDPCP/KDN Eng/Sp) ·         NDEP’s  Tips to Help You Stay Healthy ·         NDEP’s Take Care of Your Feet for a Lifetime (online) ·         LEAP - Lower Extremity Amputation Prevention Program (http://www.hrsa.gov/leap/ ·         Diabetes Basics (KDPCP, Eng & Sp) ·         Living Well with Diabetes Fast Guide (Krames, Eng & Sp KDN’s My Personal Diabetes Health Card (Eng/Sp) (1-502-564-799 ·    Gestational Diabetes (Krames) ·    It’s Never Too Early to Prevent Diabetes (NDEP, Eng & Sp) ·    Have Diabetes? A Flu Shot Could Save Your Life! (KDPCP) ·    NDEP’s Tips for Helping a Person with Diabetes (online) ·    Diabetes Basics (KDPCP, Eng & Sp)	*Diabetes Basics and Nutrition Basics are booklets addressing very basic diabetes information that can be used until the individual can attend diabetes self-management classes, have nutrition consult, or see the health care team.  They are not intended to take the place of diabetes management classes, meal planning, or visiting the health care team. Encourage the individual/family to call the local health center or hospital to register for classes and to see a dietitian for an individualized meal plan. Guide to Diabetes Education Materials that Are Free or Low Cost is a resource available from the Kentucky Diabetes Network, Inc. website http://www.kentuckydiabetes.net. NDEP’s Working Together To Manage Diabetes, Diabetes Medication Supplement Diabetes Numbers at-a-Glance (NDEP)   NDEP’s ·       Guiding Principles of Diabetes Care ·       Team Care: Comprehensive Lifetime Management for Diabetes ·       Take Care of Your Heart. Manage Your Diabetes (16 languages) ·       You Are the Heart of Your Family…Take Care of It, Flipchart Presentation (bilingual-English and Spanish) ·       Feet Can Last a Lifetime: A Health Care Provider’s Guide to Preventing Diabetes Foot Problems ·       The Power to Control Diabetes Is in Your Hands Other professional and patient resources: http://chfs.ky.gov/dph/info/dpqi/cd/diabetes.htm www.diabetes.niddk.nih.gov or call (800) 860-8747 www.cdc.gov/diabetes or call (877) 232-3422 www.kentuckydiabetes.net Kentucky Diabetes Resource Directory https://apps.chfs.ky.gov/KYDiabetesResources

Table 1 – Summary of recommendations for adults with diabetes         

Glycemic control

            A1C                                                                 <7.0%*

            Preprandial capillary plasma glucose               70­­–130 mg/dl

            Peak Postprandial capillary plasma glucose** <180 mg/dl

Blood Pressure                                                             <130/80 mmHg

Lipids***

            LDL                                                                 <100 mg/dl (<70 mg/dl in some with CVD)

            Triglycerides                                                    <150 mg/dl

HDL                                                                >40mg/dl (men), >50 (women) (Note: >60 is low risk)

Key concepts in setting glycemic goals:

·         A1C is the primary target for glycemic control

·         Goals should be individualized based on:

o   Duration of diabetes

o   Pregnancy status

o   Age/life expectancy

o   Comorbid conditions

o   Known CVD or advanced microvascular complications

o   Hypoglycemia unawareness

o   Individual patient considerations

·         More or less stringent glycemic goals (i.e. a normal A1C <6%) may be appropriate for individual patients.

·         Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals.

*Referenced to a nondiabetic range of 4.0–6.0%.

**Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

***Current NCEP/ATP III guidelines suggest that in patients with triglycerides > 200 mg/dl, the “non-HDL cholesterol” (total cholesterol minus HDL) be utilized.  The goal for the non-HDL cholesterol is

30 mg/dL higher than LDL goal.

Table 2 – Correlation of A1C with estimated average glucose (eAG)*:

                                                            Mean plasma glucose

                A1C (%)                                          mg/dl

                                    6                                                                                                    126

                                    7                                                                                                    154

                                    8                                                                                                    183

                                    9                                                                                                    212

                                  10                                                                                                  240

                                  11                                                                                                  269

                                  12                                                                                                  298

*(The ADA and American Association of Clinical Chemists have determined that the correlation is strong enough to justify reporting both an A1C result and an estimated average glucose (eAG) result when a clinician orders the A1C test.  A calculator for converting A1C results into eAG is available at http://professional.diabetes.org/eAG. )

             

References:

1. The Art and Science of Diabetes Self-Management Education, A Desk Reference for Healthcare Professionals, American Association of Diabetes Educators, 2006
2. American Diabetes Association, Clinical Practice Recommendations, 2011
3.  AADE 7 Self Care Behaviors, http://www.diabeteseducator.org Professional Resources/AADE7/National Diabetes Education Program, 2010
4. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2003
5. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001

Hypoglycemia in Individuals with Diabetes

Symptoms	Mild Hypoglycemia Shakiness Dizziness Sweating Hunger Pale skin color Headache Tingling sensations around the mouth Moderate Hypoglycemia Sudden moodiness or behavior changes, such as crying for no apparent reason Clumsy or jerky movements Difficulty paying attention, or confusion Drowsiness Aggressiveness Severe Hypoglycemia Altered states of consciousness, including coma or seizure (which requires treatment with glucagon* or IV glucose)
If blood glucose is low (usually 70 or below), follow the “Rule of 15”. Test blood glucose, if feasible, but do not delay treatment to check blood glucose. Treat hypoglycemia immediately!	Rule of 15: 1.  Eat or drink something containing 15 grams of carbohydrate:  3–4 glucose tablets 15 grams of glucose gel 4–6 ounces of fruit juice or regular soft drink (not diet) 1 cup of milk 1 Tbsp of sugar, jelly, or honey 2 Tbsp of raisins 1 piece of fruit 2.  Rest for 15 minutes. 3.  Recheck blood glucose. 4.  If still low (below 70), repeat #1, #2, and #3 (until blood glucose is above 70). 5.  If next meal is more than 1 hour away, eat a light snack to keep from going low again.
Give glucagon if: 1. patient is unconscious 2. patient is unable to eat sugar or a sugar-sweetened product 3. patient is having a seizure 4. repeated administration of sugar or sugar-sweetened product (i.e. regular soft drink or fruit juice) does not improve the patient’s condition) If glucagon is not available, call 911.	Glucagon Administration 1.  Glucagon should be injected subcutaneously or IM in buttock, arm, or thigh.  2.  This can be done by anyone (i.e. family member, friend, health care professional, etc) who has been taught how to give an injection.  3.  Anyone receiving glucagon should be turned on their side as sometimes it can cause vomiting.  Recommended doses for Glucagon: Adults and children > 20 kg (44 pounds): 1 mg subcutaneous or IM.  If necessary, the dose may be repeated after 15 minutes. Children < 20 kg (44 pounds): 0.5 mg subcutaneous or IM or 20 to 30 mcg per kilogram (9.1 to 13.6 mcg per pound) of body weight.  If necessary, the dose may be repeated after 15 minutes.  THERE IS NO DANGER OF OVERDOSE.
After a hypoglycemic episode, the body’s ability to respond to another drop in blood glucose may be lowered, thus increasing the potential for further hypoglycemic events.