Sick day management in patients with diabetes

Acute illness typically leads to hyperglycaemia in patients with diabetes, but may lead to hypoglycaemia in patients on sulfonylurea and/or insulin therapy with reduced oral intake

Patients with diabetes may develop significant hyperglycaemia when unwell due to:

Stress response of illness
Reduced physical activity
Altered diet
The need to withhold oral hypoglycaemic agents
Treatment with glucocorticoids

Consequently, all patients with diabetes should have a sick day management plan if they become unwell with any acute illness which should include:

Notifying somebody that are unwell and to avoid strenuous activity
Monitoring their glucose levels at least 3-4 times per day or immediately if symptomatic of hypo- or hyperglycaemia
To stop SGLT2i in acute illness or at least 3 days (including day of) before any major elective procedure or any elective procedure that involves reduced oral intake for > 12 hours (including dental surgery). Also need to stop SGLT2i at least 3 days before any bowel prep (e.g. colonoscopy) or a low carbohydrate diet (e.g. bariatric surgery) pre-procedure. The SGLT2i should not be restarted until the patient is well and eating and drinking normally
Patients on SGLT2i need to attend their GP practice or hospital if they have any symptoms of diabetic ketoacidosis (DKA) such as nausea, vomiting or abdominal pain to ensure their capillary ketone levels are normal (remember glucose levels may be falsely normal in SGLT2i-induced DKA).
In acute gastrointestinal illness to also stop metformin and acarbose (restart when well)
Ensuring they remain well hydrated (aim for 1 glass of water per hour)
Avoid NSAIDs if they have diabetic renal disease and/or on ACE inhibitor/ARB therapy
To continue eating as per normal or light meals if not tolerated
If reduced oral intake, patients on sulfonylureas and bolus insulin will likely to reduce or omit their doses. Patients on basal or premixed insulin may need to reduce their doses by 20-30% to prevent any hypoglycaemia (base any reduction on patient's glucose levels). Patients on high doses of basal insulin or Ryzodeg insulin may need a greater than 30% reduction, particularly those on twice daily Ryzodeg insulin.
Correction insulin can be used every 4 hours to treat any hyperglycaemia

To contact their primary diabetes provider or emergency services (if required) if:

Significantly unwell (particularly if fever, vomiting or diarrhea)
Blood glucose levels persistently > 20 mmol/L or frequently < 4 mmol/L

The use of high dose glucocorticoids (e.g. > prednisone 20 mg/day or dexamethasone 2 mg/day) will likely lead to significant hyperglycaemia that may require temporary intensification of therapy including an approximate 30% increase in insulin doses during the day.

Insulin-naïve patients may need to start insulin therapy with glucocorticoids, particularly if high doses (e.g. ≥ 20 mg of prednisone or 2 mg of dexamethasone per day) or prolonged courses
Intermediate acting NPH insulin (e.g. Protaphane, Humulin N) in the morning will likely best match the steroid-induced hyperglycaemia pattern. Consider addition of other insulin if required based on blood glucose levels.

Consider acute referral to secondary care if acutely unwell and:

Intercurrent illness requires referral regardless of glucose and ketone levels
Capillary ketone levels > 1.5 mmol/L
Glucose levels persistently > 25 mmol/L or hyperglycaemic symptoms
Any concerns over the development of HHS (hyperosmolar hyperglycaemic syndrome)
Severe hypoglycaemia or high risk of severe hypoglycaemia

Type 2 Diabetes Management Guidelines

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