This is one of the few calls where treatment precedes assessment. Say: “Treat it now” — and for an adult inpatient with diabetes who is conscious and can swallow safely, JBDS 01 means 15–20 g of fast-acting oral carbohydrate, rechecked at 10–15 minutes. Outside that population, or outside the UK, use the local hypoglycaemia protocol; if not, call for help, protect the airway, IV glucose where there is access, and intramuscular glucagon only where there is not — remembering that glucagon works badly in the malnourished, the fasted, the alcoholic and the cirrhotic, which is a fair description of the patients most likely to need it — then the recheck, then long-acting carbohydrate — that last step assuming he has recovered and can safely eat. Nil by mouth, unsafe swallow, enteral feeding or a variable-rate insulin infusion each take a different route through the protocol, and none of them is a biscuit.
Then ask: What insulin or sulfonylurea did he get, and when? Is he eating? Kidney function? Was there a missed meal or a procedure fast?
The hypoglycaemia is easy. The reason is what will hurt them at 5 a.m.
- Sulfonylureas cause prolonged, relapsing hypoglycaemia. One treatment is not a treatment. How long you watch is agent- and protocol-specific, not a single number: JBDS flags risk persisting 24–36 hours after a last dose of sulfonylurea or long-acting insulin, longer with renal impairment, and leaves the observation period to be individualised — but recurrent, severe, deliberate, long-acting or renally impaired means monitored observation, senior advice, and often an infusion rather than another round of dextrose. Ask about octreotide, and ring toxicology; they will not mind the hour. This is the classic overnight miss
- Long-acting insulin given before a fast, a missed meal, or an interrupted feed
- New or worsening renal failure reducing insulin clearance — the dose that was right last week is now an overdose
- Sepsis, adrenal insufficiency, liver failure, alcohol as non-diabetic causes
- Reduced oral intake that nobody adjusted the insulin for
FIRST MOVES Treat, recheck, feed. Then interrogate the chart: which agent, what dose, what time, against what intake. Make a documented plan for the next dose and for overnight review rather than leaving a note for the day team — the recurrence usually happens before they arrive — and if the change is substantial, the cause unclear, the kidneys failing, or the patient not diabetic at all, that plan gets a senior or the diabetes team attached to it. Set the recheck frequency explicitly. If he is on a variable-rate insulin infusion, open the protocol before you give carbohydrate and keep going regardless. Check the swallow before anything oral. In a sulfonylurea-associated event, plan for a long tail. And recurrent hypoglycaemia in a non-diabetic deserves the critical sample — laboratory glucose, insulin, C-peptide, ketones, sulfonylurea screen, cortisol — drawn during the episode and before the rescue where that costs no time at all. Not another biscuit.
Ward call: [AGE]-year-old [SEX], day [X] for [REASON]. Capillary glucose [X] mmol/L at [TIME]. Conscious level [X], able to swallow [Y/N]. Treated with [WHAT] at [TIME]; repeat glucose [X]. Diabetes: [TYPE 1 / TYPE 2 / NONE]. Glucose-lowering drugs: [AGENT, DOSE, TIME GIVEN — insulin type matters]. Oral intake today: [X]. Fasting for a procedure: [Y/N]. Creatinine [X] (baseline [X]), eGFR [X]. Liver disease: [Y/N]. Alcohol: [Y/N]. Steroids recently stopped: [Y/N]. Sepsis: [Y/N]. Tell me how long I must monitor this specific patient given the agent involved, and whether this one needs a glucose infusion rather than repeated boluses. Name the agent most likely responsible and the immediate safety actions. Then tell me whether the next dose needs urgent senior or diabetes-team review under local protocol — do not hand me a fixed dose change without the full regimen, nutrition plan, renal function and trajectory, and do not simply park it with the day team either, because the recurrence usually arrives before they do. Then non-diabetic causes worth excluding.