Sick Day Guidance for Type 1 Diabetes

• Introduction
• What causes your blood glucose levels to rise?
• What impact will being ill have on your diabetes?
• Managing your diabetes when you are ill
• Insulin adjusting
• Ketone monitoring

Introduction

If you have diabetes, it is very important that you know what to do when you are ill.

When you are ill your body becomes much more resistant to the insulin you produce or take by injection. This means that your blood glucose levels can rise and it is likely that you will need to increase your insulin dose. You therefore need to monitor your blood glucose and ketone levels very carefully. We refer to this as ‘sick day guidance’.

What causes your blood glucose levels to rise?

Illnesses and other conditions that could increase your blood glucose levels include:

• Cold, flu or similar virus
• Stomach upset
• Sore throat
• Urinary infection
• Chest infection
• Abscess
• Broken bone
• Taking a steroid tablet or injections for another condition

What impact will being ill have on your diabetes?

The impact on your diabetes will usually depend on whether you have a minor or more severe illness.

Minor illness

This is when your blood glucose is either within the normal range or raised but with no ketones in your blood or urine (e.g. a minor viral infection or minor injury).

Severe illness

This is where your blood glucose is raised and ketones are positive in your blood or urine (e.g. a chest infection or another more severe infection). Your raised blood glucose may also be caused by missed insulin injections. Remember that testing positive for ketones is a sign that you are low on insulin.

For more information on this, see the NHS/Diabetes UK flow chart for guidance.

It is important to remember that when you are ill, you must monitor your blood glucose levels closely and you should never stop taking your insulin.

Managing your diabetes when you are ill

• If you are vomiting, you do not need to eat until you feel well enough to try, but keep sipping fluids to prevent dehydration. You should drink at least 100 ml per hour.
• If you do not feel like eating normal meals, try to eat foods that are easy to digest, e.g. soup, ice cream, milk puddings.
• If your blood glucose falls below the normal range, sip full-sugar drinks, fruit juice, sweetened tea or Lucozade (make sure it's full sugar), or suck an ice lolly.
• If you have an infection that is not clearing up, you should make an appointment to see your GP to determine whether you need further treatment.
• If you continue to vomit, are unable to keep fluids down and/or can't manage to reduce your blood glucose or ketone levels you must seek medical advice immediately or go to your nearest A&E department.
• Adjusting your insulin doses will help to control your blood glucose levels (see the NHS/Diabetes UK flow chart and the information given below).

Insulin adjusting

You may need to adjust your insulin regime if your illness is causing your blood glucose to be raised and/or ketones to be present in your blood or urine. Extra insulin will correct hyperglycaemia and clear the ketones.

• If your blood glucose level is higher than 10 mmol/L, then you should increase your usual insulin dose by 10%.
• You should also administer an extra dose of insulin to stabilise your blood glucose. Calculate the extra dose as 10–20% of your total daily dose. For example, if your total daily dose is 40 units, 10–20% will be a dose of 4–8 units.
• Use short-acting insulin for the extra dose, e.g. Actrapid, Novorapid,  Humalog or Apidra.
• Recheck your blood glucose and ketones in 1–2 hours.
• Repeat the extra dose at intervals of 2–4 hours if necessary.
• If you are in any doubt, or if you are unable to keep checking your blood glucose and ketones, then contact your diabetes care team or call an out-of-hours service

Ketone monitoring

In addition to monitoring your blood glucose, you should also check your ketone levels when you are unwell, particularly if your blood glucose is higher than 14 mmol/l on more than one occasion.

If your ketones are elevated (above 0.6 mmol/L) and you have any of the following symptoms:

• High blood glucose with excessive thirst passing urine
• Dehydration
• Vomiting
• Abdominal pain
• Breathlessness

then you must go to A&E immediately as you may have diabetic ketoacidosis. If you are pregnant and have raised ketone levels, then you should go to A&E even if you have no other symptoms.

For advice on what to do when ketone levels are moderately raised but you have no severe symptoms, see Table 1 below. You should always seek medical advice if your ketones are above 3.0 mmol/L.