‘Sick days’ refer to when you have an intercurrent sickness or illness to manage in addition to Diabetes that requires changes to the usual diabetes self-management practices.
Intercurrent illness refers to the occurrence of a new disease in the presence of another one although both illnesses may not be necessarily related. For example, a diabetic patient may develop an intercurrent bout of pneumonia.
People living with well controlled Diabetes do not experience more infections or illness than the general population. However, individuals with consistent poorly controlled blood glucose may experience reduced immunity resulting in:
Increased risk of acquiring infections
Higher chances of the infections spreading quickly.
Increased risk of unusual infections.
Enhanced risk of infections from organisms that are normally not pathogenic.
Poor response to antibiotic therapy.
Regardless of the cause, intercurrent illness such as: common cold or flu including COVID 19; sore throat; urinary tract infections; bronchitis or chest infections; stomach infections; and skin infections (especially if these conditions are accompanied by a fever or high temperatures) can affect Diabetes management in several ways. Illnesses may cause:
hyperglycemia
hypoglycemia or
no significant effect on blood glucose
However, intercurrent illness usually results in hyperglycemia due to:
higher levels of stress hormones
enhanced production of glucose by the liver even from non-carbohydrate sources like proteins and fats
insulin resistance
This situation is usually made worse by emotional stress; erratic use of insulin and/or other diabetes medicine; alcohol abuse; and medications that increase blood glucose levels e.g. corticosteroids. Even a minor illness can lead to dangerously high blood sugar levels. This may lead to life threatening complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state.
For this reason, people living with diabetes, their care givers, and parents of children living with Diabetes should work with their healthcare team to make an illness plan covering the following:
Their target blood sugar goal during an illness
How to adjust their medicine (for example how to adjust their insulin dosage and when to take their insulin)
Frequency of checking their blood sugar and ketone levels
When to contact their doctor for help
The following guidelines address some of these core issues
Guideline for people with type 1 Diabetes
During a period of illness:
Insulin treatment should never be stopped
The insulin dose may need to be increased and it might be necessary to take additional doses of fast-acting insulin to bring down the blood sugar levels
Blood glucose levels should be checked at least every four hours
Plenty of carbohydrate-free fluids like water should be drunk to avoid dehydration.
Ideal blood sugar levels should be between 6-10mmol/l (110-180 mg/dl)
Recommendations for insulin adjustment for Type 1 Diabetics on basal bolus insulin (Those on basal only or premixed insulin regimen should contact their doctor for advice on insulin adjustment)
The Total Daily Dose (TDD) formula helps to decide how much extra rapid or fast acting or supplemental insulin a person needs to take in addition to the usually prescribed dose of insulin to correct hyperglycemia.
Add up the number of units of insulin (all kinds) that you usually take each day: TDD = ____units
Calculate 10%; 15%; and 20% of TDD. This is the extra dose of rapid or fast acting insulin that you need to take.
Follow the chart below to decide exactly how much fast/rapid acting insulin to take every four hours in addition to the usual baseline insulin doses. Repeat insulin every 4 hours if needed as per the chart below.
If not eating as usual, replace the usual carbohydrates with sugar containing fluids but the amount should be carefully controlled to prevent blood sugar readings from rising too much.
-
Blood sugar tests
(mmol/l)
Blood and urine ketone tests
(mmol/l or urine specific)
ACTION NEEDED
Below 4.0mmol/l ————————————- - Increase blood glucose level with carbohydrate – 15-15 hypo treatment until blood sugar is above 4.0 mmol/l
- No extra Insulin. Decrease dose of pre-meal insulin as directed.Column 2 Value
4.0-8.0mmol/L Blood – less than 0.6mmol/l Urine – negative
Use usual insulin dose as for normal (non-illness) days. 4.0-8.0mmol/L Blood- 0.7 to 1.4 mmol/l Urine – Small
Use usual insulin dose as for normal (non-illness) days.
4.0-8.0mmol/l Blood – Greater than or equal to 1.5mmol/l Urine – moderate /large
- 5% supplemental insulin may be required
- Recheck blood glucose and ketones in 2-4 hours
- Seek urgent medical help if ketones remain present
8.1-15.0mmol/l Blood – less than 0.6mmol/l Urine – negative
- May fall without extra insulin
- If persistently elevated consider 5% supplemental insulin
- Recheck glucose and ketones in 2-4 hours
8.1-15.0mmol/l Blood- 0.7 to 1.4 mmol/l Urine – Small
- If persistently elevated consider 5-10% supplemental insulin
- Recheck glucose and ketones in 2-4 hours
8.1-15.0mmol/l Blood – Greater than or equal to 1.5mmol/l Urine – Moderate/large
- If persistently elevated consider 10% supplemental insulin
- Recheck glucose and ketones in 2-4 hours
- If ketones remain present seek urgent medical assistance
Greater than 15mmol/l Blood – less than 0.6 mmol/l Urine – negative
- Take a 10% supplement of rapid or fast-acting insulin, addition to usual baseline insulin doses.
- Consume carbohydrate free fluids
- Recheck glucose and ketones in 2-4 hours
- If unable to reduce glucose levels after 2 supplemental doses of insulin seek urgent medical assistance
Greater than 15mmol/l Blood- 0.7 to 1.4 mmol/l Urine – Small
- Take a 15% supplement of rapid or fast-acting insulin, in addition to usual baseline insulin doses.
- Consume carbohydrate free fluids
- Recheck glucose and ketones in 2-4 hours
- If unable to reduce glucose levels after 2 supplemental doses of insulin seek urgent medical assistance
Greater than 15mmol/l Blood – Greater than or equal to 1.5mmol/l Urine – Moderate/large
- Take a 20% supplement of rapid or fast-acting insulin, addition to usual baseline insulin doses.
- Consume carbohydrate free fluids
- Recheck glucose and ketones in 2-4 hours
- If unable to reduce glucose levels after 2 supplemental doses of insulin seek urgent medical assistance
Guideline for people with type 2 Diabetes
The sick day plan should be commenced immediately if the person with diabetes is feeling unwell or has any signs of illness, even if the blood glucose levels are still normal.
Test blood glucose every four hours, and keep track of the results
Drink plenty of fluids – 120 to 180 ml every half an hour to prevent dehydration. It might also be necessary to drink sugary beverages if it is not possible to take in 50 grams of carbohydrates through food. The amount of sugary beverages should nevertheless be carefully controlled to prevent blood sugar levels from rising too much.
Weigh yourself every day. Losing weight while eating normally is a sign of high blood glucose
- Individuals taking insulin may require extra insulin when unwell. If the person with diabetes is currently administering a basal/bolus insulin
regimen, they can be advised to use the supplemental insulin advice as prescribed for those with type 1 diabetes. People with diabetes taking a
basal only or premixed insulin regimen, should be advised to contact their diabetes care team for advice on insulin adjustment. Most patients should be advised to continue taking their usual medications even if they are eating little or are vomiting and/or diarrhoearing. However as vomiting and/or diarrhoea can cause rapid dehydration, patients taking the following medications may need to consult their doctor on how to proceed with medication due to increased risk of complications
- Metformin – dehydration increases the chances of developing a serious side effect called lactic acidosis
- Sulfonylureas – if you are unable to eat or drink, you are more likely to develop low blood glucose (hypos) Examples: names ending with ‘ide’ such as gliclazide, glibencamide, glipizide. If you are eating and drinking normally and blood sugars are high continue taking Sulfonylureas
- GLP-1 analogues –dehydration can make it more likely that you will develop a serious side effect. • Examples: names ending with ‘tide’ such as exenatide, dulaglutide, liraglutide, lixisenatide and semaglutide
- SGLT2 inhibitors – dehydration can make it more likely that you will develop a serious side effect called ketoacidosis. Examples: names ending with ‘flozin’ such as canagliflozin, dapagliflozin, empagliflozin and ertugliflozin
- ACE inhibitors – these medicines are used for heart conditions, high blood pressure and for kidney protection. If you are dehydrated, these medicines can stop your kidneys working properly. Examples: names ending in ‘pril’ such as ramipril, lisinopril, perindopril, captopril
- ARBs – these medicines are used for heart conditions, high blood pressure and for kidney protection. If you are dehydrated, these medicines can stop your kidneys working properly. Examples: names ending in ‘sartan’ such as candesartan, irbesartan, losartan, valsartan
- Diuretics – these medicines are used to control excess fluid and high blood pressure and are sometimes called ‘water pills’. These medicines increase the chances of dehydration. Examples include bendroflumethiazide, furosemide, indapamide, bumetanide.
- NSAIDs – these are anti-inflammatory pain killers. If you are dehydrated, these medicines can prevent your kidneys from working properly. Examples include ibuprofen, naproxen
When to Seek Immediate Medical Attention
Vomiting or diarrhea occurring for more than 2–3 hours or if it becomes blood or bile stained
You cannot keep any food or fluids down
Blood glucose levels >15.0mmol/L despite 2 supplemental insulin doses.
Blood ketone levels >1.5mmol/L/ or urine ketone levels moderate/large and not decreasing following 2 doses of supplemental insulin.
Blood ketone levels >0.6mmol/L in people with type 1 diabetes who have a history of recurrent DKA, very poor glycaemic control, eating disorders, a known history of frequent inappropriate omission of insulin, pregnancy, multiple co-morbidities such as end-stage organ failure, who are elderly or live in a remote/isolated area far away from medical support.
Severe dehydration (symptoms may include increased thirst, dry mouth and swollen tongue, weakness, dizziness/fainting, palpitations, headache, confusion/delirium, inability to sweat, decreased or no urine output).
Persistent hypoglycaemia
If the person has a known complex medical history, end-stage organ failure, is frail and elderly.
Experiencing symptoms of Diabetes Ketoacidosis such as: abdominal pain and nausea, trouble breathing, fruity breath, severe dry mouth, or confusion
Experiencing symptoms of Hyperosmolar Hyperglycemic State such as severe dry mouth, warm and dry skin that does not sweat, high fever, confusion, hallucinations, and loss of vision.
