Getting prepared for sick days is an essential part of diabetes self-management. Everyone gets sick at some point or another, even healthy people or people with diabetes. However, acute illness in people with diabetes can be complicated with hypoglycaemia, hyperglycaemia, dehydration, and diabetic ketoacidosis. Learning how to manage diabetes during sick days can help prevent these complications and hospital admissions.
Glucose monitoring
During acute illness or stress events, the hormones that stimulate blood glucose production, like cortisol and catecholamines, will be increased. This will lead to hyperglycaemia, which if untreated, can lead to dehydration and diabetic ketoacidosis. On the other hand, people who are acutely ill also tend to have reduced appetite and consume less carbohydrate, which predisposes them to hypoglycaemia. In general, the blood glucose direction can be shifted upwards or downwards to cause hyperglycaemia or hypoglycaemia, with very limited ways to predict its direction.
Given this risks, it is important for people with diabetes to check their blood glucose during episodes of acute illness. Most people will require blood glucose checks every 4 to 6 hours, depending on the severity of their illness, their current blood glucose levels, and their oral intakes. In the event of hypoglycaemia, more frequent blood glucose testing will be needed.
Medication adjustments
In general, medications for diabetes, high blood pressure, high cholesterol, and most other medications should be continued at the same doses. However some diabetes medications are worth mentioning:
Basal insulin
Basal insulin should be continued at the same dose and timing during acute illness. Reducing or omitting the dose of basal insulin during an acute illness can cause severe hyperglycaemia and diabetic ketoacidosis.
Prandial insulin
Prandial insulin, mealtime insulin, or short- or rapid-acting insulin should be adjusted based on the amount of carbohydrate intake. If carbohydrate intake is very little, prandial insulin can be skipped. However, a small amount of short- or rapid-acting insulin may be needed if blood glucose is significantly high (> 15 mmol/L).
Oral medications
Most of the time, oral medications can be continued at the same doses and timings. Some diabetes care providers may advise to stop SGLT-2 inhibitors, ACE-inhibitors, angiotensin receptor blockers, and diuretics during acute illness, but these decisions need to be taken on a case-to-case basis. Note that non-steroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal bleeding and renal impairment during acute illness, and should be avoided unless absolutely necessary.
Treatment for hyper- and hypoglycaemia
In people with diabetes who are treated with insulin, additional doses of short- or rapid-acting insulin can be administered if blood glucose is > 16 mmol/L at 10% of the total daily insulin dose. Blood glucose monitoring needs to be repeated after 4 hours, and if hyperglycaemia is persistent, they are advised to seek medical help. Hypoglycaemia can be treated using the 15 x 15 method, described in the "Hypoglycaemia" section.
When to seek medical help
One should seek medical attention immediately in the event of:
1. Persistent hyperglycaemia > 16 mmol/L
2. Recurrent hypoglycaemia < 3.9 mmol/L
3. Severe hypoglycaemia, requiring help for treatment and recovery
4. Symptoms of diabetic ketoacidosis, such as breathlessness, abdominal pain, or vomiting
5. Symptoms of severe dehydration, such as giddiness upon rising up or extreme lethargy
6. Increasing severity or worsening of the acute illness
7. Difficulty in managing diabetes or other medical illness at home
Additional resources
A good patient leaflet by the NHS UK on sick day management for people with type 2 diabetes can be found here.