Sick Day Management

Lori Laffel, MD, MPH

Endocrinology and Metabolism Clinics of North America. 2000;29 (4):707-723.

Never Omit Insulin

• Insulin must be taken during illness, even if eating is greatly diminished.
• Infection promotes insulin resistance; therefore, increased or supplemental doses of insulin are often required to manage hyperglycemia and ketosis.
• Monitors that measure β-hydroxybutyrate are now available and may help determine the appropriate dosage of supplemental insulin and may improve sick-day management.

 

Prevent Dehydration and Hypoglycemia

• Oral hydration is preferred.
• During times of nausea and vomiting, attempts at oral hydration with frequent small quantities of clear fluids are recommended.
• If vomiting persists, the patient's healthcare team should be notified immediately.
• Blood sugar levels will determine whether patients should consume sugar-containing or sugar-free fluids.

 

Monitor Blood Sugar Frequently

• Blood sugar monitoring should be performed at least every 2-4 hours.
• If blood sugar is low, more frequent monitoring is recommended.
• Careful records should be maintained to track illness progression and detect early signs of decompensation before the development of frank ketoacidosis.

 

Monitor for Ketosis

• The availability of blood monitors that measure β-Hydroxybutyrate has revealed the weaknesses of urine ketone testing.
• Blood measurement of β-Hydroxybutyrate "may be a better guide to insulin therapy in home management of ketosis".
• The need for ketone testing during illness must be reinforced

 

Provide Supplemental Fast-Acting or Rapid-Acting Insulin

• During any period of intercurrent illness, blood sugar and ketone levels should be monitored every 2-4 hours.
• "Supplemental doses of fast-acting (regular) or rapidly acting (lispro) insulin should be administered in addition to usual insulin dosages whenever hyperglycemia and ketosis are present.

 

Treat Underlying Triggers

• Viral infections not requiring specific prescriptive therapy may still elevate blood glucose and produce ketosis, making sick-day management necessary.
• Patients with a history of recurrent diabetic ketoacidosis (DKA), known eating disorders or psychosocial problems, or poor glycemic control are at risk for decompensation.
• These patients should call their health care team at the first sign of illness or decompensation.

 

Maintain Frequent Contact With the Medical Team

• Patients and family members need to look for signs that medical attention is needed, including:
• Continued vomiting lasting more than 2-4 hours
• Blood glucose > 300 mg/dL
• Persistent ketones for more than 12 hours
• Signs of dehydration, including dry mouth, weight loss or sunken eyes
• Symptoms of DKA development, including nausea, abdominal or chest pain, ketotic breath, hyperventilation or altered consciousness

 

Conclusions

• Sick-day management requires increased monitoring of blood glucose and assessment for ketosis.
• The American Diabetes Association states that blood ketone testing is preferred over urine ketone testing as a more reliable method of diagnosing diabetic ketoacidosis.¹

 

References

1 © 2004 American Diabetes Association. From Diabetes Care, Vol. 27, Supplement 1, 2004; S91-S93. Reprinted with permission from The American Diabetes Association. This is not intended to be taken as an endorsement by the American Diabetes Association.

DOC08938-Rev-B 03/07