Written by Michelle Archer, RD, CDE of Diabetes Training 101 Inc.

Fear of Hypoglycemia and Hypoglycemia Treatment Options in Canada

In Part 1 of my Update to the Diabetes Canada CPG Hypoglycemia Chapter blog post, we reviewed the new classification system for hypoglycemia created by the International Hypoglycemia Study Group and discussed the importance of asking about episodes of hypoglycemia at each visit with a diabetes professional.

New to the Hypoglycemia Chapter: Fear of Hypoglycemia

In addition to the updated hypoglycemia classification system, there is also now a section on Fear of Hypoglycemia (FoH). Inclusion of FoH is an important step in clinical practice that acknowledges in our published literature the mental health toll of hypoglycemia on people living with diabetes. The new section defines Fear of Hyperglycemia, FoH screening tools and treatment strategies. People living with diabetes will often tell their health team that they are afraid of low blood sugar so they will intentionally keep their blood sugar higher to avoid having lows. That approach makes us concerned about the long-term effects of this practice on blood vessels, but we all understand why an individual would want to avoid hypoglycemia at any cost. Hypoglycemia and its symptoms are personally quite scary and often leave the person feeling terrible for hours afterwards – plus they often are a huge disruption to a person’s day. I think it’s very positive that FoH is now acknowledged and discussed in the Diabetes Canada Clinical Practice Guidelines.

Hypoglycemia Treatment Options

The hypoglycemia treatment section is worth a read. The recommended treatment for hypoglycemia is 15 grams of a monosaccharide glucose – preferably glucose, dextrose or sucrose tablet which raises blood sugar levels about 2 mmol/L within 20 minutes. Diabetes educators know that chewing and swallowing the glucose source is the way to treat low blood sugars, but many people living with diabetes will either undertreat “(I treated my low with a candy”) or they don’t get the sugar into themselves fast enough (they suck on the candies either because they rarely have candy and want to enjoy the taste, or possibly because of loss of or sore teeth preventing chewing of a harder sugar source). When it comes to treating low blood sugars, people need to get the sugar into them as fast as they can to counter the symptoms and effects of the hypoglycemia (often related to the effects of medications, insulin, or exercise). The literature states that 20 grams of oral glucose will produce a rise in blood sugar of about 3.6 millimoles at 45 minutes and this is the preferred treatment option of severe hypoglycemia in a conscious person. In an individual who is on insulin, an individual who is very sensitive to insulin, or an individual who may have cognition issues where they may forget if they’ve taken their insulin, 20 grams glucose can be recommended to offer a more robust glycemic response. Oral forms of glucose treatment including glucose gel must be swallowed to be effective.

Glucagon Treatment of Hypoglycemia

If an individual is having frequent hypoglycemia, they are living with Type 1 Diabetes, or they are on Multiple Daily Injections (MDI) and living with Type 2 Diabetes, glucagon treatment of level 3 hypoglycemia should be discussed. To briefly recap, glucagon is an opposing hormone to insulin and the job of glucagon is to help the liver and muscles release glucose from glycogen stores through the process of gluconeogenesis and glycogenolysis. Glucagon comes in a few different forms:  3mg internasal (IN) glucagon, 1mg subcutaneous (SC) and 1mg intramuscular (IM). 1 milligram glucagon given SC or IM produces a significant blood sugar increase ranging from 3-12 millimoles/L within an hour in individuals with glycogen stores. Glucagon is the treatment of choice in severe hypoglycemia in an unconscious person. Intranasal glucagon has been shown to be as effective as subcutaneous and intramuscular glucagon in individuals with T1D, and individuals with T2D treated with insulin.

In the updated Diabetes Canada CPG chapter, it was noted that there are real world studies where intranasal glucagon has successfully treated unconscious individuals in stage 3 hypoglycemia. People often use what they have in the moment and the examples of IN glucagon working for treatment of severe hypoglycemia in some real-world case is great news!

Considerations When Discussing Glucagon

There are a few patient lifestyle and health scenarios worth assessing when discussing glucagon use in diabetes.

Low Carb Diets – If an individual is following a low carb diet/keto/modified keto, their treatment response to a dose of glucagon is not well defined. One of the outcomes of following a low carb diet is decreased glycogen storage so it is unclear if an individual will be able to produce a robust enough glycogen or endogenous glucose response to treat the low.

Alcohol Use – The effectiveness of glucagon is reduced in people who have had more than two standard alcoholic drinks in the past few hours, especially if they are in a prolonged fasting state including individuals who follow intermittent fasting.

Advanced Hepatic Disease – In those who have advanced hepatic disease, their ability to create and release glucose in response to glucagon may be impaired.  Liver glycogen stores are the main source of glucose in response to a glucagon injection and it is unclear how a damaged liver may respond in this situation.

These are just three important points for us to be considering and discussing with our clients who are following some of those atypical or non-traditional diets such as low carb or intermittent fasting, those who may have advanced hepatic disease, and for those who take insulin or a sulfonylurea diabetes drug.

Practice Directives for Diabetes Education

Towards the end of the hypoglycemia chapter, in Figure 1, you will find several informative points on education, prevention and treatment. Included are discussion points to put into your EMR or your follow-up forms. It is helpful that there is now a bulleted list of topics that you can reference to make sure that you’re not missing any key parts of addressing hypoglycemia with your patients.

Also in Figure 1 is a table around prevention strategies covering 4 key areas.

  1. Psychoeducational training – within your structured diabetes programs.
  2. Choice of Pharmacotherapy – considering the diabetes medication action for your patient. Reviewing their pattern of lows and considering if there is a more effective or as effective treatment option that has no hypoglycemia risk that we could recommend and that the patient can afford. And if there aren’t suitable options, a second-generation basal insulin analogue can be considered for that client as the newer, longer acting insulins offer less risk of hypoglycemia.
  3. Continuous Glucose Monitoring (CGM) – The use of CGM has been revolutionary for anyone who is using insulin but has also delivered “A-HA” moments to many living with diabetes. Promote CGM coverage and use in our patients if they can access and afford them.
  4. Surgical Prevention Strategies – Lastly, there are surgical prevention strategies. Islet Cell Transplants and Pancreatic Transplants have promise to restore the glucagon response in Type 1 Diabetes. At the time of writing this blog post, I was unclear about the physiology of the glucagon response in Type 1 Diabetes and that led me to dig into the literature and remind myself why the glucagon response is impaired in Type 1 Diabetes. What I found there was really fascinating. Stay tuned for that in another blog post.

If you are looking for a better understanding of hypoglycemia in adults living with diabetes, I encourage you to check out Chapter 14 of the Diabetes Canada Clinical Practice Guidelines. For additional tools or learning opportunities on hypoglycemia, the International Hypoglycemia Study Group has a number of free resources on their website.

Happy reading!


  1. Yale, Jean-Francois MD, CSPQ, FRCPC et al. Canadian Journal of Diabetes.  Volume 42, Supplement 1, S104-108, April 2018.
  2. Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Chapter 14- Hypoglycemia in Adults Diabetes https://guidelines.diabetes.ca/cpg/chapter-14-2023-update
  3. Building Competencies in Diabetes Education: The Essentials. Diabetes Canada. Chapter 8, 8-29 – 8-33