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ARTICLE OF THE MONTH

Doctor, Doctor I am sick,
Help my bloodsugar very quick!
(Diabetes sick day guide)

By: Florence A. Santos, MD, FPCP, FPSEDM, FACE
Internal Medicine
Endocrinology

When a patient with diabetes gets sick, how are they suppose to deal with their bloodsugar? There had been many questions, beliefs and even misconceptions when it comes to what-to-do and what-not-to-do for patients with diabetes.

Blood sugar and stress

Getting sick can be a form of stress. Blood sugar and stress form an unwanted duo. Our body has counter regulatory hormones (i.e. glucagon, cortisol, epinephrine) which tend to elevate during stress and illness resulting in decreased insulin secretion hence, resulting to high blood glucose. This is why despite loss of appetite, patients note rise in blood sugar and difficulty in reaching their targets. In patients with Type 1 or Type 2 diabetes mellitus, this condition can lead to diabetic ketoacidosis (DKA). Checking urine ketones is one way of knowing if a patient has DKA. Urine ketones can be checked through a test strip and may indicated as trace, low, moderate, high and very high. Some test strips may be interpreted with “plus signs” such as +, ++ or +++ which stand for the severity of ketosis. Elderly people with Type 2 diabetes mellitus during stressful condition may have severe dehydration which leads to hyperglycemic hyperosmolar syndrome (HHS). Both conditions, DKA and HHS are life threatening and warrants hospitalization to address dehydration, hyperglycemia and underlying causes such as infection.

Hydrate, hydrate, hydrate

Water is essential during hyperglycemia triggered by illness. It is important that a patient is well hydrated because it can trigger DKA and HHS if confronted with a severely dehydrated patient. When a patient is at home, a cup of fluids every hour would suffice. Carbohydrate-free fluids such as water and ice chips are preferred. However, when a patient is having nausea and vomiting and has a very poor food intake, glucose containing fluids such as fruit juices may be allowed. Instruct patients to have small, frequent amounts of liquids. The level of blood sugar will determine if patient should consume sugar-containing or sugar- free fluids. Other drinks which may be taken are broth-based soup, sports drinks, diet soda and plain tea. However, if vomiting is persistent and intake of fluids cannot be tolerated, bringing the patient to the hospital for intravenous hydration is recommended.

Don’t be afraid to eat

It is important to stick to the normal meal plan when one is sick. But for some, this may be difficult since having fever, diarrhea, nausea and vomiting make it impossible for them to have a normal diet. If it is only soft diet which can be tolerated, try soup, gelatin, yogurt, pudding, frozen juice bars and crackers. Low carbohydrate intake accompanied by dehydration can cause accumulation of ketones in the blood during starvation, termed as “starvation ketosis”. This is a metabolic condition wherein the body breaks down fats and produces acid which is being used as energy instead of using glucose. This is the reason why it is essential to maintain a normal calorie intake especially during illness.

Never miss medications and insulin

It is a common misconception that due to a patient’s poor food intake during illness, medications and insulin can be missed. On the contrary, one should maintain his medications because the body is producing extra glucose during sick days. Remember that illness brought by infection creates a state of insulin resistance hence, a patient on insulin may need additional doses and those on oral medications may need rescue doses of insulin. However, the doses of medications may be adjusted accordingly when a patient has persistently low levels of blood glucose due to continuous poor food intake.

Prick more!

It is recommended that checking of blood sugar should be more often during sick days. Some may have very low blood sugar due to food intake or very high blood sugar due to stress due to illness. By monitoring 2-4 times a day, one can determine if glucose containing fluids or high-carbohydrate diet may be allowed especially if patient experiences hypoglycemia. The dosing of medications and insulin will also be dependent of results of glucose monitoring whether patient has hypo- or hyperglycemia.

When to call the doctor

Contact the doctor if:

  • Had fever for 2 days

  • Having diarrhea and vomiting for 6 hours

  • Cannot take any fluids, even small amounts or sips of clear liquids

  • Blood glucose levels are way off target even if with additional insulin ( usually > 250mgs/dl)

  • Moderate or high urine ketones

  • Any signs of dehydration

It is also important that symptoms of diabetic ketoacidosis are recognized:

  • Thirst or a very dry mouth

  • Frequent urination

  • High blood glucose levels (typically over 250 mg/dl, although ketones can occur at lower levels)

  • High levels of ketones in the urine or blood

  • Constantly feeling tired

  • Dry or flushed skin

  • Nausea, vomiting or abdominal pain

  • Difficulty breathing

  • Fruity odor on the breath

  • A hard time paying attention, or confusion

Keeping all these in mind will help a patient with diabetes manage himself during sick days. To help them stay out of the hospital, one needs to know how to recognize and manage symptoms. But, one must also know when to contact his doctor for further management.

References:

  1. http://www.diabetes.org/living-with-diabetes/treatment-and-care/whos-on-your-health-care-team/when-youre-sick.html?referrer=https://www.google.com.ph/#sthash.HIjO111U.dpuf

  2. American Diabetes Association. Managing Diabetes on Sick Days

  3. 2004 American Diabetes Association. From Diabetes Care, Vol. 27, Supplement 1, 2004; S91-S93.