1. Diabetes – sick day rules

2. Scenario Katie is a 15 year old girl with diabetes 3 day history of cough productive of green sputum, shortness of breath and feeling generally unwell Has been drinking plenty of fluids, but not eating much as feeling unwell and has a reduced appetite

3. Diabetes and intercurrent illness Stress of illness can increase basal insulin requirements Patient may be unable to monitor and manage their condition as well as they normally would when unwell

4. Insulin requirements and illness Some diabetics may associate insulin dosing with eating, so during a period of anorexia or vomiting they may feel that they do not need to take their normal insulin regime Insulin should not be stopped as hyperglycaemia can arise from intercurrent illness irrespective of the patient’s calorie intake Need to maintain carbohydrate intake

5. Insulin – sick day rules Patients should increase the frequency of glucose monitoring to 4 hourly or more as necessary Guide for adjusting insulin: – Blood glucose less than 13mmol/L: continue with current dosage – Blood glucose 13-22mmol/L: patient should increase by 2 units each injection, even if unable to eat – Blood glucose greater than 22mm/L: patient should increase by 4 units each injection, even if unable to eat – Return dose to normal when blood glucose returns to normal

6. Insulin – sick day rules contd Patients should test for ketonuria once or twice a day, more frequently if ketones are present Glucose and ketone monitoring should continue until the glucose level returns to 13mmol/L or below, a normal diet is being taken and ketones are absent from the urine

7. Other considerations Treat the underlying cause of the intercurrent illness sufficiently Maintain carbohydrate intake using sugary drinks or fruit juice, soups or snack foods if the patient has difficulty eating Fluid intake – advise to have a glass of water every hour, aiming for 3L/24 hours Antiemetics mat be useful, but establish likely cause of symptoms first and admit if necessary

8. Safety netting Patients should be advised to seek medical advise if: – Unable to eat or drink – Persistent diarrhoea or vomiting – Blood glucose higher than 25mmol/L despite increasing insulin – Very low glucose levels – Persistent ketones or large amounts of ketones in the urine – Become drowsy or confused (ensure parents/carers aware of this) – Any other concern

9. When to admit Underlying diagnosis that requires admission Inability to swallow or keep fluids down – admit if persists for more than a few hours Significant ketosis in a type I diabetic despite optimal management and supplementary insulin Persistent diarrhoea BM persistently >20mmol/L

10. When to admit contd. Clinical signs of ketosis or deteriorating condition e.g. Kussmaul’s respiration, severe dehydration, abdominal pain Patients unable to manage adjustment of normal diabetes care Patients who live alone and have no support who may be at risk of slipping into unconsciousness