Individualize Sick Day Management for Diabetes

Patients with diabetes will ask you how to manage sick days.

Stress from acute illness can cause HYPERglycemia...but less food intake due to poor appetite or vomiting can cause HYPOglycemia.

Emphasize plenty of fluids to prevent dehydration...and small servings of sweetened beverages (juice, etc) if patients can’t eat.

Also help individualize management of meds.

Oral meds and non-insulin injectables. Advise most patients to NOT automatically stop these meds...even if they can’t eat.

But if a patient is at risk for hypoglycemia due to limited intake, suggest holding sulfonylureas, repaglinide, or nateglinide.

Advise holding SGLT2 inhibitors or metformin with vomiting or severe diarrhea. This could increase risk of ketoacidosis or kidney injury with SGLT2 inhibitors...or rare lactic acidosis with metformin.

Recommend restarting when patients resume eating and drinking.

Refer for prompt evaluation if needed...such as if blood glucose is over 300 mg/dL for 2 tests over several hours in a patient who’s usually well managed. Short-term insulin may be needed.

Insulin. Educate NOT to stop insulin when patients are sick. But explain that doses may need to be adjusted.

For example, if glucose is over 250 mg/dL, suggest adding about 5% to 20% of the total daily insulin dose to the patient’s rapid-acting insulin (lispro, etc)...based on glucose, intake, and ketones.

On the other hand, if patients on insulin can’t consume adequate carbs, recommend lowering or skipping BOLUS doses.

Advise patients to continue BASAL insulin (glargine, etc).

Testing. Recommend more frequent blood glucose testing during an acute illness, such as every 2 to 4 hours for patients on insulin...or about 2 to 4 times a day for patients not on insulin.

Also advise patients with type 1 diabetes to test ketones while sick...especially if glucose is persistently over 250 mg/dL.

But explain that ketone testing isn’t needed for most patients with type 2 diabetes...since diabetic ketoacidosis is rare.

Refer for emergency care if patients have prolonged vomiting, can’t keep down fluids, or have persistent hyper- or hypoglycemia.

Key References

  • Am J Kidney Dis. 2023 May;81(5):564-574
  • (5-23-23)
Pharmacist's Letter. June 2023, No. 390601


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