Management of Intercurrent Illness

The majority of people with intercurrent illness can be managed at home. However intercurrent illness is the most common precipitant of diabetic metabolic decompensation.

Acute Illness in People treated with Insulin

• All people with diabetes should receive education on sick day rules.
• Insulin should NEVER be omitted (even if not eating).
• Insulin requirements are usually increased during illness/stress. The amount of insulin required will depend on individual circumstances.
• Frequent blood glucose monitoring is essential.
• Carbohydrate intake should be maintained e.g. soup, ice cream, lucozade.
• Increased oral fluids (4-6 litres in 24hrs) advised.
• Consider admission if vomiting.
• If in doubt contact local Diabetes Team for advice.

Acute Illness in Non-Insulin Treated people

• All people with diabetes should receive education on sick day rules
• Blood glucose levels will usually rise in response to stress or illness
• Short term hyperglycaemia can be tolerated
• Can be managed at home if no evidence of severe dehydration and the individual is able to increase oral fluids appropriately
• Oral diabetes medication should normally be continued
• Metformin should be temporarily stopped if there is severe infection or dehydration.As per Highland Formulary guidelines and British National Formulary
• Admission to hospital is advised if the individual is severely dehydrated or intractable vomiting

If in doubt contact local Diabetes Team for advice

Prevention of Ketoacidosis in people with Type 1 diabetes (Sick Day Rules )

MAIN MESSAGE IS:
NEVER STOP TAKING INSULIN or ORAL HYPOGLYCAEMIC AGENTS except for Metformin.

All people should be

• The individual should be advised that during any illness their blood glucose levels or urine tests are likely to rise, and that they should check their levels more often at least 4 hrly
• If glucose levels are above 17mmol/l check urine or blood for ketones. 
• If positive more than a trace ( urine) or 1.0mmol/l .Rapid acting insulin should be administered ( See paediatric guidelines for children and illness).The amount of insulin required will depend upon individual circumstances but in general an extra dose of 1/6th of the total daily dose will be required. ( maximum single dose 15units).
• If blood glucose remains high and ketones present 4 hours later then the extra dose can be repeated.If glucose remains high and ketones are present after 12 hours then hopital admission is required
• Discontinue Metformin whilst unwell.
• Increase sugar free fluid intake.
• If blood glucose is less than a2mmol/l and ketones are positive this may be caused by starvation ketones and carbohydrate should be increased.
• If unable to tolerate normal foods choose other sources of carbohydrates such as; fruit juices, fizzy drink (not diet), milk, ice cream, jelly, porridge, soups, milk puddings, biscuits etc.
• Usual remedies such as Paracetamol and cough medicines etc may be taken according to manufacturers instructions. Sugar free cough medicine is available, but regular cough medicine in small amounts will not be harmful.
• The individual should be advised to contact their GP or the Diabetes team if they are worried.
• If persistent vomiting or diarrhoea occurs; blood glucose levels are consistently above 17 mmols despite extra insulin; or the person is obviously unwell a hospital admission should be sought. Ketocard should be provided for people with Type 1 diabetesrapid breathing or abdominal pan are signs that ketoacidosis is established and requires urgent hospital assessment.
• Once recovered insulin doses can return to normal