Beyond A1C – Preventing and Treating Severe Lows in Type 2 Diabetes

Key Takeaways:

• Severe hypoglycemia is not a type 1 problem alone. Risk concentrates in patients treated with insulin or insulin secretagogues, and it climbs with age, comorbidity burden, and long diabetes duration.
• The 2026 American Diabetes Association (ADA) Standards of Care recommend glucagon for all individuals taking insulin or at high risk for hypoglycemia, yet real-world glucagon prescribing remains very low.
• Rescue readiness means more than a prescription: a ready-to-use formulation plus a close contact who knows when and how to use it.

Most clinicians associate glucagon rescue with type 1 diabetes, and that association quietly leaves a large group of type 2 patients without a plan for a severe low. Severe, or level 3, hypoglycemia is defined as an event with altered mental or physical status requiring assistance from another person, and it has been linked to mortality in major glycemic trials.¹

For the substantial share of patients with type 2 diabetes on insulin or secretagogues, the question is not whether severe hypoglycemia can happen but whether anyone is ready when it does.

Where the risk concentrates

Clinically significant hypoglycemia is common among patients taking insulin or insulin secretagogues such as sulfonylureas, and rare among those on other glucose-lowering classes. In observational data, emergency department visits or hospitalizations for hypoglycemia occur at roughly 2.0 per 100 person-years among insulin or sulfonylurea users, versus 0.2 per 100 person-years among patients on other agents.^1,2

Risk is not evenly distributed: Hypoglycemia is most common in older patients, those with multiple or advanced comorbidities, long diabetes duration, or a prior history of hypoglycemia.²

Event rates rose to 2.3 per 100 person-years in patients aged 75 years and older and to 3.5 per 100 person-years in those with 2 or more comorbidities. Reduced ability to recognize and communicate symptoms, along with impaired counterregulation, makes older adults with type 2 diabetes particularly vulnerable.^1,2

A persistent prescribing gap

The 2026 ADA Standards of Care are direct: Glucagon should be prescribed for all individuals taking insulin or at high risk for hypoglycemia. The guidance also notes that appropriate glucagon prescribing is very low in current practice, and that clinicians should routinely review patients' access to glucagon.¹

The gap, in other words, is one of implementation rather than evidence. Identifying the at-risk patient, the patient on basal-bolus insulin, the older patient on a sulfonylurea, the patient with prior severe events, and confirming that a current rescue product is actually in hand is a concrete, repeatable step that fits into a routine visit.

Choosing a usable rescue

Glucagon was traditionally dispensed as a powder requiring reconstitution before injection, a multistep process that is difficult to perform correctly under the stress of a real event. Intranasal and ready-to-inject preparations are now widely available and, per the ADA, are preferred for their ease of administration and more rapid correction.¹

Usability data bear this out: In simulated severe-hypoglycemia rescue, trained users were far more likely to find nasal glucagon easy to use (87.1% versus 54.8%) and to prepare (80.6% versus 51.6%) than reconstitutable injectable glucagon, and most users preferred the nasal route.³

Efficacy is comparable across routes. In a pooled analysis of controlled studies in adults with type 1 and type 2 diabetes, 97 to 100% of patients achieved treatment success within 15 to 30 minutes with either nasal or injectable glucagon, with less rebound hyperglycemia after the nasal product.⁴

Common adverse effects are manageable and route-specific: nausea, vomiting, and headache across products, plus transient nasal symptoms with the intranasal formulation; glucagon is contraindicated in pheochromocytoma and insulinoma.^5,6

Making rescue readiness routine

A prescription only helps if someone can act on it. An individual does not need to be a healthcare professional to administer glucagon, and the ADA recommends that close contacts, family members, roommates, or coworkers be shown where the product is kept and when and how to use it. Pairing the right at-risk patient with a usable formulation and an informed bystander is what turns a prescription into readiness.¹