Suffering an illness can affect a diabetic patient’s glucose (blood sugar) levels and cause serious conditions that can lead to a coma or possibly death. To prevent complications, patients should develop a sick-day management plan in advance with their diabetes care team. When patients become ill, they will then know how to react and have supplies on hand.

A sick-day management plan may include:

• How often to perform glucose monitoring
  
  
• How often to perform a ketone test
  
  
• What medications or changes in medication may be needed
  
  
• What foods and fluids to consume
  
  
• When to call the physician
  
  
• What to do in case of emergencies such as severe dehydration, hypoglycemia or hyperglycemia

Illness puts stress on the body and can alter a person’s glucose (blood sugar) levels. When a person is sick with a cold, the flu, or an infection, the body releases hormones that help fight the illness. These hormones, however, interfere with the glucose-controlling effects of insulin and can raise and sometimes lower the level of glucose. As a result, it is harder for patients with diabetes to control their glucose when they are ill.

Illness can also lead to diabetic ketoacidosis (DKA), particularly in people with type 1 diabetes. DKA includes severe hyperglycemia and ketosis and typically involves a lack of insulin. Instead of breaking down glucose, the body begins to break down fats to use for energy, producing a waste product called ketones. The body is incapable of releasing all of the ketones through urine, so they begin to build up in the blood (ketosis). Although it usually develops slowly, the condition can develop in only a few hours once vomiting occurs. DKA is considered a life-threatening emergency and requires immediate medical attention.  Untreated, DKA can lead to a diabetic coma or death.

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a dangerous condition in which a person experiences severe hyperglycemia and dehydration. This condition is seen more frequently in older people and occurs more often with type 2 diabetes. HHNS is usually brought on by illness. If not treated, it can lead to seizures, coma or death.

Women should know how diabetes can affect their pregnancy and be alert for indications of possible complications. A particular concern is preeclampsia, a condition marked by elevated blood pressure and proteinuria (protein in the urine).

To prevent an illness from causing major problems, patients should work out a sick-day management plan in advance with their physician, dietitian and certified diabetes educator.  Then when patients become ill, they will know how to react and have the supplies on hand to treat themselves. A sick-day management plan should include:

• How often to perform glucose monitoring
  
  
• How often to perform a urine test or blood test for ketones
  
  
• How often to take the temperature
  
  
• Whether other tests such as blood pressure readings or microalbuminuria testing need to be performed
  
  
• What changes in diabetes medication or other medication may be needed
  
  
• What over-the-counter medications are good choices and when to take them
  
  
• What foods and fluids to consume
  
  
• Whether exercise needs to be limited or suspended
  
  
• When to call the physician
  
  
• What should be done in case of emergencies such as severe hypoglycemia, fainting or coma

When ill, people with diabetes will have to take special steps to control glucose (blood sugar) and avoid dehydration and ketosis. It is important to note that the following are general guidelines that would be pre-empted by the instructions of an individual’s physician, certified diabetes educator or registered dietitian. Steps in managing an illness may include:

• Continuing insulin and antidiabetic agents. It is essential for patients to take their normal doses of insulin and antidiabetic agents, even when vomiting or not eating much. The diabetes medications counteract the extra glucose the body is producing to fight the illness.

People who use insulin, such as those with type 1 diabetes, may need to take additional insulin to bring down their high glucose levels. In addition, patients with type 2 diabetes who take antidiabetic agents may need to adjust their dose or take insulin for a short time. The sick-day management plan should address what changes in medication may be necessary, and what glucose levels require a change in dosage of insulin or antidiabetic agent.

Patients who take glucose-lowering drugs such as biguanides should consult the physician about whether to stop taking or reduce the dose during a serious illness. If an illness causes low blood pressure, lactic acidosis is a potential side effect of biguanides (e.g., metformin), which may need to be temporarily replaced with insulin injections.

• Carefully choosing other medication. Patients who decide to take cough medication and other over-the-counter drugs should be aware of the ingredients. Some medications contain sugar. Although a small dose of medication containing sugar may not cause problems, the sugar can add up when taking a dose every four or six hours, as is often suggested. Sugar-free medication is often a good alternative. However, when medication containing sugar is taken, the patient should account for the medication's carbohydrates in the meal plan.
  
  Some over-the-counter medications contain alcohol, which can lower glucose levels. Choosing alcohol-free medication is a safer alternative. However, when medication containing alcohol is taken, the patient may need to eat something to avoid hypoglycemia (low blood sugar).

In addition, large doses of aspirin can lower glucose levels, and some antibiotics can lower glucose levels in people who take antidiabetic agents. Decongestants can raise glucose levels and blood pressure. Other drugs that can raise glucose levels include corticosteroids, other immunosuppressives and diuretics.

Common painkillers including aspirin can damage the kidneys, especially in patients with diabetic nephropathy (kidney disease).

To be safe, patients should discuss any medication with their physician before taking it. They should ask their physician which medications are best for them and add a list of those medications to their sick-day management plan. To be prepared for an illness, the patient should make an effort to have those approved medications on hand. Patients should also be aware of which medications may require an adjustment in insulin, antidiabetic agents or diet.

• Checking levels of glucose and ketones frequently. People with diabetes may have to monitor their glucose levels more frequently when they are ill. A patient’s sick-day management plan should recommend how often testing will be necessary. Those with type 1 diabetes may need to check their glucose and ketone levels every three to four hours.

Ketones are waste products that are more likely to build up when a patient is sick. Testing the blood or urine for ketones is important because they can lead to diabetic ketoacidosis. If the ketone levels are high or the patient is pregnant, ketone tests may need to be performed more often.

Patients with type 2 diabetes may need to check their glucose only four times a day when they are ill. In addition, they may need to test for ketones only when their glucose level is above a certain level, such as 300 milligrams per deciliter (mg/dL). If a patient has vomited or developed diarrhea, ketones may need to be checked more frequently.

A physician can recommend how often a patient should check glucose and ketone levels, and how to react when levels are too high or low. Those who are too sick to test themselves should have someone else do it for them. In addition, patients should always keep a record of their glucose and ketone test results in case a physician needs the information.

• Staying close to regular meal plan. Illness can cause a patient to eat less, which can further affect glucose levels. When possible, patients should follow their normal meal plan. They should eat at the normal times and consume the normal amount of carbohydrates or calories. Eating also keeps the body from burning fats for fuel and making ketones.
  
  Whenever it is not possible to follow the normal meal plan, the patient can try to consume the normal amount of calories by eating mild foods that are easy on the stomach. Small, frequent meals containing 10 to 15 grams of carbohydrates may be consumed every one to two hours the patient is awake.

When these bland foods are too difficult to eat, the patient can attempt to consume 50 grams of carbohydrates every three to four hours by drinking liquids. Patients with severe vomiting or diarrhea can try to sip 3 to 6 ounces (89 to 177 milliliters) of caffeine-free liquids an hour to prevent dehydration and hypoglycemia.

Fluids containing between 10 and 15 grams of carbohydrates include:

• 1/2 cup (125 milliliters) of fruit juice
• 1/2 cup of nondiet soda
• 1 cup (250 milliliters) of sports drink
• 1 cup of milk
• 1 cup of soup
• 1 double-stick popsicle

Foods containing between 10 and 15 grams of carbohydrates include:

• 1/2 cup of applesauce (unsweetened)
• 1/2 cup of cooked cereal
• 1/2 cup of regular or low-fat ice cream
• 1/2 cup of sugar-free pudding
• 1/2 cup of regular (not sugar-free) gelatin
• 1/2 cup of custard
• 1/2 cup of mashed potatoes
• 1/3 cup (80 milligrams) of rice
• 1/3 cup of frozen yogurt
• 1/4 cup (60 milligrams) of sherbet
• 6 saltine crackers
• 1 slice of dry toast or bread (not light bread)
• 6 ounces (170 grams) of yogurt (artificially sweetened or plain)

Patients should discuss sick-day food choices with a registered dietician. In addition, patients should make an effort to keep a supply of suggested foods on hand.

• Drinking plenty of noncaloric and caffeine-free fluids. Patients may be advised to drink about 8 ounces (240 milliliters) of calorie-free and caffeine-free fluids every hour they are awake. Consuming beverages such as water, decaffeinated tea and diet soda can prevent dehydration.

Dehydration is especially a concern when the patient is suffering from diarrhea, vomiting or a fever. Patients can drink bouillon or clear soup every third hour to replace sodium and other electrolytes. The additional fluids will also aid the body in getting rid of the excess glucose, and possibly ketones, in the blood. Patients with high glucose levels can drink calorie-free fluids, and patients with low glucose readings can consume fluids that contain carbohydrates.

• Knowing when to contact a physician. Although preparing a sick-day management plan enables a patient to manage an illness and prevent complications, there are times when a physician should be contacted, such as:
  
  
• The patient has been ill for one to two days without improvement
  
  
• The patient has been vomiting or having diarrhea for more than six hours
  
  
• The patient has ketones in the urine or blood for more than 12 hours
  
  
• The patient has moderate to large amounts of ketones in the urine or blood
  
  
• The patient takes insulin and is experiencing hyperglycemia above a certain level established in advance with the physician, such as 240 mg/dL, despite taking the extra doses of insulin called for in the individual’s sick-day plan
  
  
• The patient takes insulin and is experiencing hypoglycemia below a certain level established in advance with the physician, such as 60 mg/dL
  
  
• The patient takes antidiabetic agents and has a glucose level that rises before meals to a certain level established in advance with the physician, such as 240 mg/dL, and stays there for a certain period, such as more than 24 hours
  
  
• The patient has symptoms of hyperglycemia, ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome or dehydration, including:
  
  
• Polyuria (frequent urination)
• Polydipsia (excessive thirst) and dry mouth
• Kussmaul breathing (heavy, labored breathing)
• Fatigue
• Abdominal pain
• Sweet, fruity-smelling breath
• Confusion or difficulty paying attention
  
  
• The patient has had a fever of 101 degrees Fahrenheit (38 degrees Celsius) that keeps rising or has lasted for more than a day
  
  
• The patient has lost 5 pounds or more during the illness
  
  
• The patient is unsure or has questions about what self-care to take

People with diabetes are encouraged to attach a list of phone numbers to their sick-day management plan. The list should include day, night and weekend contact numbers for their physician, dietitian and diabetes educator.

• Keep written records. A physician contacted by a patient will need to know certain information. In addition to recording glucose and ketone test results, people with diabetes should weigh themselves every day and check their temperature every morning and evening when they are sick. To have this information handy, patients should begin to record the details of their illness as soon as they become sick. Examples of information that should be recorded include:
  
  
• How long the patient has been sick
  
  
• What insulin doses and antidiabetic agents have been taken, when they were taken and how much was taken
  
  
• What other medication has been taken
  
  
• Whether the patient can eat and drink, and keep it down
  
  
• What food and fluids have been consumed and how much
  
  
• Whether the patient has lost weight
  
  
• What the patient’s temperature is
  
  
• What the patient’s glucose levels have been since becoming ill
  
  
• What the patient’s ketone levels have been since becoming ill
  
  
• Whether the patient has experienced vomiting or diarrhea and, if so, for how long
  
  
• What other symptoms have been experienced
  
  
• The telephone number of the patient’s pharmacy

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about sick days and diabetes:

1. How often should I check my glucose when I’m sick?
   
   
2. How often should I perform ketone testing?
   
   
3. How often should I weigh myself?
   
   
4. Are there any other tests I should perform when I’m sick, such as blood pressure?
   
   
5. Do I need to adjust my diet when I’m sick? What dietary changes should I avoid? Should I work with a registered dietitian on this?
   
   
6. What should I do if I can’t eat or keep food down?
   
   
7. Should I change my exercise routine when I’m not feeling well?
   
   
8. How will illness alter my use of insulin or other diabetes medication?
   
   
9. Will I need to avoid or adjust the dosage of any of my nondiabetes prescription medications when I’m ill?
   
   
10. Which over-the-counter medications or supplements are safe for me, and which should I avoid?
    
    
11. When there is a problem with a matter such as my blood sugar, ketones or blood pressure, at what point is it a condition I can treat myself and at what point do you consider it an emergency?
    
    
12. What plan should I have in case of emergencies such as severe hyperglycemia, hypoglycemia, dehydration, ketoacidosis or diabetic coma?
    
    
13. If my emergency plan includes glucagon, who should be trained in administering it? Where is such training available?