Illness Management
For adults with Type 1 Diabetes on a basal bolus regime
What happens to my diabetes when I am ill?
When you are ill your blood glucose levels tend to increase even if you are unable to eat or are being sick. When you are ill your body becomes more resistant to the insulin you inject. This means that your blood glucose levels can rise and there is a risk of developing Diabetic Ketoacidosis (DKA), a potentially life threatening condition.
Although you may not feel like it, it is very important to monitor your diabetes closely to prevent such conditions occuring.
What is Diabetic Ketoacidosis (DKA)?
When blood glucose levels continue to rise it is due to a lack of insulin. Without treatment this leads to a serious condition called diabetic ketoacidosis, which requires urgent hospital treatment.
If there is not enough insulin, carbohydrate cannot be used to provide essential energy so the body breaks down its fats stores to use for energy instead.
This leads to the production of ketones (a type of acid), which are dangerous at high levels.
Ketones can be detected in the urine or blood.
As ketone levels increase you may feel very unwell, start vomiting or become short of breath or drowsy or confused. If left untreated it can be extremely dangerous.
How can I prevent DKA?
Never stop taking your background insulin or long acting insulin as your body needs this all the time; we cannot survive without an adequate insulin supply.
Act immediately - do not wait for your diabetes to become out of control
Make sure you have access to ketone testing strips (either blood or urine) which have not reached their expiry date
If you feel unwell, or your blood glucose levels are regularly above 13mmol/l, follow the advice below on "insulin adjustments when ill"
Avoid strenuous exercise if ketones raised (above 1.5mmol/l in the blood; "+" or more in the urine)
Insulin adjustment when ill
If you are feeling unwell, or your blood glucose levels are regularly above 13mmol/l, test your blood or urine for ketones and follow the guidance as indicated below:
If ketones are less than 1.5mmol/l (blood) or "trace" or negative (urine);
Treat as Minor Illness
Insulin Adjustment
Test blood glucose and ketones every four hours
Take the usual dose of quick acting insulin with meals if eating, plus corrective insulin if blood glucose raised
Use extra quick-acting insulin as you normally would to reduce blood glucose, even if not eating
You may only need long-acting (background) insulin if not eating - give the usual dose
If ketones rise to 1.5mmol/l or above, follow Severe illness guidance
Ketone present - Severe Illness
If blood ketone levels are 1.5mmols/l or higher ("+" or more in urine) this is classed as severe illness.
Blood glucose is usually above 13mmol/l.
Insulin Adjustment
Test blood glucose and ketones every two hours (through the night as well as during the day)
Calculate total daily dose from previous day
Give additional quick-acting insulin as indicated below in Step 1
Step 1
Ketones 1.5 - 3.0mmol/l (blood) or +to ++ (urine) Give 10% TDD as QA insulin every 2 hours (as well as usual QA insulin with meals and usual BI) If ketone levels increase to above 3mmol/l, follow step 2. Once ketone levels reduce to less than 1.5mmol/l (or negative/trace urine), follow Minor Illness guidance.
Step 2
Ketones above 3mmol/l (blood) +++ to ++++(urine) Give 20% TDD as QA every 2 hours (as well as usual QA insulin with meals and usual BI)
Once ketones reduce to 1.5 - 3.0mmol/l (or less than +++ urine), follow guidance for step 1 or minor illness guidance if less than 1.5mmol/l (or negative/trace urine)
Calculating Total Daily Dose (TDD) of insulin
Total Daily Dose (TDD) is the total amount of insulin you take in a typical day. This includes background insulin (BI) and quick acting insulin (QA) insulin.
Example of how to calculate TDD
Previous days total amount of QA insulin = 26 units
Previous days total amount of BI insulin = 24 units
Total daily dose (TDD) 26 units+24 units = 50 units
Suggestion: make a note of your total daily dose of insulin from yesterday (or a typical day) and calculate 10% and 20% of this dose.
|
Some abbreviations/terms used in guidance: QA: Quick-Acting insulin e.g. Humalog, Novorapid, Apidra or Fiasp usually taken with meals BI: Background Insulin, or long-acting Insulin e.g. Lantus, Detemir, Abasaglar, Tresiba or Toujeo TDD: Total Daily Dose - Total amount of insulin taken usually in a day (i.e. all quick-acting insulin taken with meals and background insulin doses added together) Corrective: extra quick-acting insulin taken to 'correct' a raised glucose level. If you are unsure what your sensitivity is to corrective insulin is, assume 1 extra unit may reduce your glucose by up to 3mmol/l. |
Table for use as a guide to help calculate either 10% or 20% of your TDD
|
TDD |
10% |
20% |
|
15-20 |
2 |
3 |
|
25 |
3 |
5 |
|
30 |
3 |
6 |
|
35 |
4 |
7 |
|
40 |
4 |
8 |
|
45 |
5 |
9 |
|
50 |
5 |
10 |
|
55 |
6 |
11 |
|
60 |
6 |
12 |
|
65 |
7 |
13 |
|
70 |
7 |
14 |
Food and fluid intake during illness
During illness you may not wish to eat normal meals. If this is the case, try to have alternative food or drinks that contain carbohydrate and are easy to digest, e.g. ice cream/milky drinks/soup. Having some carbohydrate may help reduce further ketone formation.
Sip sugar-free fluids (at least 100ml each hour) to reduce the risk of dehydration.
If you are unable to eat, use sugary drinks such as fruit juice or full sugar cola to treat any hypos.
If you feel sick, you do not need to eat until you feel well enough to try, but keep sipping fluids to prevent dehydration.
What if things are not improving?
Seek urgent medical attention if:
You continue to vomit and/or are unable to keep fluids down
Your ketone levels do not improve despite having more than two increased insulin doses
You become drowsy or confused
You or your carers feel unable to manage your diabetes
You are feeling more unwell
You may need to seek medical advice to treat the cause of your illness.
This information is not a comprehensive and detailed guide; if you have any questions or require further explanation please do not hesitate to ask a member of your diabetes team.
Diabetes
How to manage illness - For adults with Type 2 diabetes taking medication - including insulin
What happens to my diabetes when I am ill?
When you are ill your blood glucose levels tend to increase even when you are unable to eat or are being sick. When you are ill your body's own insulin does not work as well. This means your blood glucose levels can become increased. As the glucose levels rise, you may develop symptoms of thirst or a dry mouth, or passing more urine than usual. You may also notice that you feel lethargic. On rare occasions, if the glucose levels become too high, this could result in a medical emergency requiring hospital admission.
What should I do?
For people taking medication (but not insulin) for their diabetes
Generally advice is to continue with your usual diabetes medication, even if you are not eating as normally do. Below is a list of common diabetes treatments and further information about whether you should continue taking or not.
Metformin
Continue taking as normal, unless you are severely unwell (e.g. diarrhoea, vomiting or fever) when it could be stopped temporarily. It should be stopped if you are so unwell that you are unable to get out of bed.
Acarbose
Continue taking as normal, unless you are vomiting or have diarrhoea, when it could be stopped temporarily.
Gliclazide, Glimipiride, Glipizide, Nateglinide, Repaglinide
Continue taking as normal. If you are unable to eat and drink you may be at risk of hypo's (low blood glucose levels) so the dose may need to be reduced or stopped temporarily. If you are unable to eat, use sugary drinks such as fruit juice or lucozade to treat any hypo's. You may need to test your blood glucose levels more frequently during illness to check for potential hypoglycaemia.
Pioglitazone
Continue taking as normal. Seek medical advice if you are unusually short of breath.
Linagliptin, Saxagliptin, Sitagliptin, Vildagliptin, Alogliptin
Continue taking as normal. Seek medical advice if vomiting or severe abdominal pain.
Exenatide, Liraglutide, Lixisenatide, Dulaglutide (injections), Semaglutide (injections or tablets)
Continue taking as normal. Seek medical advice if vomiting or severe abdominal pain.
Dapagliflozin, Canagliflozin, Empagliflozin
As this is a new medication, there is little experience with use during illness so you may need to seek medical advice. It may need to be temporarily stopped if you become dehydrated.
Insulin adjustments when ill
If your blood glucose is less than 13mmol/l - take your normal insulin dose. If it is more than 13mmol/l - take a larger dose as directed below:
13 -17mmol/l - add 2 extra units to each dose of insulin
17 -22mmol/l - add 4 extra units to each dose of insulin
More than 22mmol/l - add 6 extra units to each dose of insulin
If you are taking more than 50 units a day in total, you should double these adjustments.
Once you have given this initial increased dose, contact your GP, Practice Nurse or Diabetes Specialist Nurse for advice if you feel unsure about adjusting your insulin doses further.
Continue to test your blood glucose every 4 hours
If the level remains above 13mmol/l, follow the advice regarding increased doses of insulin.
If the level is less than 13mmol/l, adjust the insulin back down to your normal dose.
The doses should be decreased again gradually as the illness subsides.
Food and fluid intake when ill
During illness you may not wish to eat normal meals. If this is the case, try to have alternative food or drinks that contain carbohydrate and are easy to digest, e.g, ice cream, milky drinks, soup.
Sip sugar-free fluids (at least 100ml each hour) to prevent dehydration.
If you are unable to eat, use sugary drinks such as fruit juice or lucozade to treat any hypo's.
If you feel sick, you do not need to eat until you feel well enough to try, but keep sipping fluids to prevent dehydration.
What if things are not improving?
Seek urgent medical attention if:
You continue to vomit and/or are unable to keep fluids down
You become drowsy or confused
You or your carers feel unable to manage your diabetes
Your blood glucose levels do not improve despite increased insulin doses (if you usually take insulin)
You may need to seek medical advice to treat the cause of your illness.
This information is not a comprehensive and detailed guide; if you have any questions or require further explanation please do not hesitate to ask a member of your diabetes team.