Management of Individuals With Diabetes at High Risk for Hypoglycemia

Publication Date: December 7, 2022
Last Updated: November 14, 2023



This patient guideline summarizes key takeaways from the Endocrine Society (ES) guideline for the management of individuals with diabetes at high risk for hypoglycemia. The purpose of this guideline is to provide new evidence-based recommendations on critical issues affecting adults and children with diabetes at high risk for hypoglycemia.



  • Hypoglycemia is a common occurrence in people with diabetes, especially if they are taking medications like insulin or sulfonylureas (SU).
  • Hypoglycemia is a low blood sugar level that can cause various symptoms and complications in individuals with diabetes.
  • It can cause distress for individuals with diabetes and their families, leading to difficulties in managing their condition and affecting their daily life and work.
  • Hypoglycemia can also result in expensive emergency department visits and hospitalizations, and it can have serious health consequences and even lead to death.
  • There are different insulin types and action profiles (rapid, intermediate, and long-acting) that allow insulin regimens to be tailored to an individual's needs for optimal blood glucose management.

Management Overview

Management Overview

Continuous Glucose Monitoring (CGM) for Type 1 Diabetes:
  • The use of CGM is recommended instead of fingerstick self-monitoring of blood glucose for patients with Type 1 Diabetes who receive multiple daily injections.
  • Comprehensive patient education is crucial for understanding how to use and interpret CGM data effectively.
  • Fingerstick blood glucose monitoring is still necessary at times to validate or confirm CGM values.
  • Both CGM and fingerstick monitoring should be accessible to patients.

Real-Time CGM for Type 1 Diabetes:
  • Real-time CGM with algorithm-driven insulin pumps (ADIPs), instead of multiple daily injections with fingerstick monitoring, is suggested for adults and children with Type 1 Diabetes, .
  • Fingerstick monitoring may still be necessary to validate or confirm CGM values in certain situations.
  • Considering use and insurance coverage, there will be times when fingerstick monitoring must be used.

Real-Time CGM for Type 2 Diabetes at Risk of Hypoglycemia:
  • Real-time CGM is suggested for outpatients with Type 2 Diabetes who take insulin and/or sulfonylureas and are at risk of hypoglycemia.
  • Professional CGM is a diagnostic tool used for short-term investigation of glycemic patterns, while personal CGM is used at home for real-time monitoring and adjustments.
  • CGM can assist patients and healthcare professionals in managing their diabetes effectively.

CGM Initiation for High-Risk Inpatients:
  • For select inpatients (persons who are admitted to a hospital or healthcare facility) at high risk of hypoglycemia, initiating CGM in the hospital setting is suggested.
  • A combination of CGM and periodic point-of-care blood glucose testing should be used to validate CGM accuracy.
    • "Point of care" refers to the location or setting where medical tests or assessments are performed during a patient's visit to a healthcare provider or in a healthcare facility. It means that the tests are conducted right there, on the spot, rather than sending samples to a laboratory for analysis.
  • Inpatient CGM use is currently not FDA-approved but has been used under specific circumstances, such as during the COVID-19 pandemic.

Continued CGM Use in the Inpatient Setting:
  • In the inpatient setting, it is suggested to continue using personal CGM with or without ADIP therapy, rather than discontinuing.
  • CGM should be combined with periodic point-of-care blood glucose (POC-BG) testing to ensure accuracy.
  • Inpatient CGM use is currently not FDA-approved but has been used under specific circumstances, such as during the COVID-19 pandemic.

Long-Acting Insulin Analogs for Basal Insulin Therapy:
  • For adult and pediatric outpatients on basal insulin therapy who are at high risk of hypoglycemia, long-acting insulin analogs are suggested instead of human Neutral Protamine Hagedorn (NPH) insulin.
    • Outpatients visit the facility for appointments, tests, or procedures and do not stay overnight.
    • NPH is an intermediate-acting insulin
  • Long-acting insulin analogs have shown a reduction in severe hypoglycemia, but their long-term effects are still being studied.
  • Patients with a history of severe hypoglycemia or medical conditions that increase their risk of hypoglycemia may benefit from long-acting insulin analogs.

Rapid-Acting Insulin Analogs for Basal-Bolus Insulin Therapy:
  • For adult and pediatric patients on basal-bolus insulin therapy who are at high risk of hypoglycemia, rapid-acting insulin analogs are suggested instead of regular (short-acting) human insulins.

Structured Patient Education for Insulin Therapy:
  • It is recommended that patients with type 1 or type 2 diabetes who are receiving insulin therapy should undergo structured patient education.
  • This education is important to learn how to prevent repeated episodes of hypoglycemia.
  • The education is provided by experienced diabetes clinicians who can guide and support patients.
  • This education aims to provide patients with the knowledge and skills necessary to manage their diabetes effectively.

Use of Glucagon Preparations for Severe Hypoglycemia:
  • For patients with severe hypoglycemia, glucagon preparations that do not require reconstitution are recommended.
    • Glucagon is a hormone that raises blood sugar levels in case of severe hypoglycemia.
  • Using the ready-to-use formulations is recommended. They are more convenient and easier to administer during an emergency.


  • ADIP: Algorithm-driven Insulin Pump
  • CGM: Continuous Glucose Monitoring
  • ES: Endocrine Society
  • NPH: Neutral Protamine Hagedorn
  • POC-BG: Point-of-care Blood Glucose
  • SU: Sulfonylurea

Source Citation

McCall AL, Lieb DC, Gianchandani R, MacMaster H, Maynard GA, Murad MH, Seaquist E, Wolfsdorf JI, Wright RF, Wiercioch W. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2023 Feb 15;108(3):529-562. doi: 10.1210/clinem/dgac596. Erratum in: J Clin Endocrinol Metab. 2022 Dec 22;: PMID: 36477488.


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.