Diabetes during intercurrent illness
Questionnaire/history:
Fever?
(Note: Some illnesses can raise blood glucose levels, especially those associated with fever)
Vomiting?
Diarrhoea?
(Note: Some illnesses can lower blood glucose levels, especially vomiting and diarrhoea but there is significant crossover)
Type 1 diabetes
(Note: No definite guidance available for type 1 diabetes)
Investigations:
Blood glucose (BG) at least every 3–4 hours including through the night, and sometimes every 1–2 hours (children every 2 hours), results to be recorded?
Test for ketones regardless of BG levels (ideally with blood ketone meter) at least every 3–4 hours including through the night, and sometimes every 1–2 hours, results to be recorded?
(Notes: Blood ketone monitoring in acute illness rather than urine testing as urine testing gives poor indicator of blood ketones, is associated with false positives, and meta-analysis evidence now suggests blood testing superior to urine in preventing DKA)
Management:
Advised:
Adequate fluid intake:
100-200 ml every hour
If blood glucose levels are normal or high use of sugar-free fluids
If blood glucose levels are low use sugary fluids:
- Pure fruit juice
- Ribena
- Milk
- Milk with drinking chocolate or Ovaltine
- Flat non-diet Coca-Cola or lemonade, but avoid carbonated drinks
If unable to keep fluids down consider antiemetic but have a low threshold for admission and IV fluids
If diarrhoea and vomiting use oral electrolyte rehydration sachets 150-300 mls per hour depending on hydration status
Carbohydrate intake:
To main normal meal pattern where possible
If unable to eat, replace meals with sugary drinks
(Notes: Insulin should never be omitted due to the risk of DKA, often insulin needs to be increased)
Negative ketones (blood < 0.6 mmol/L):
Take correction dose (CD) in addition to normal bolus
Re-check BG and ketones in 2 hours
- If BG going down, monitor closely through the day- If BG going up, but ketones < 0.6 take another CD
- If ketones 0.5-1.5 go to management regarding small-moderate ketones
- If ketones > 1.5 go to management regarding moderate-large ketones
Small-moderate ketones (blood 0.6-1.5 mmol/L):
Give 10% total daily dose (TDD) of insulin as an additional fast-acting insulin
Re-check BG and ketones in 2 hours
- If ketones negative follow the management of negative ketones
- If BG increasing, but ketones still 0.6-1.5 continue to give 10% TDD fast-acting insulin every 2 hours, in addition to usual bolus
- Re-check BG and ketones every 2 hours
- If ketones > 1.5 go to the management of moderate-large ketones
Moderate-large (blood > 1.5 mmol/lL):
Give 20% total daily dose (TDD) of insulin as an additional fast-acting insulin
Re-check BG and ketones in 2 hours
- If ketones negative follow the management of negative ketone
- If BG increasing but ketones reduced to 0.6-1.5 go to management of small-moderate ketones
- If ketones still > 1.5 give another 20% TDD fast acting
Blood glucose > 11mmol/L and blood ketones > 3.0mmol/L or +++/++++ on dipstick:
Diabetic Ketoacidosis (DKA) until proven otherwise -> Emergency referral
TDD = total of usual daily insulin requirement (including fast and slow-acting)
CD = dose required to bring BG down to normal target based on correction factor:
Correction factor = amount 1 unit of insulin will reduce BG by
Correction factor = 100/TDD
Eg if TDD is 25 units, correction factor = 100/25 = 4; 1 unit of additional fast-acting insulin would be expected to reduce BG by 4 mmol/L (eg if BG 15 and ketone negative the usual target is 7, the aim is to reduce BG by 8, CD would be 2 units (1 unit would reduce BG by 4 mmol/L, 2 units would reduce BG by 8 mmol/L etc.)
Insulin pumps:
Only give additional doses/correction dose through pump if blood ketones < 0.6 mmol/L - if one correction dose given via pump has no effect in 1 hour give subsequent additional insulin via pen
If blood ketones ≥ 0.6 mmol/L give additional insulin through pen
Stopping regular medication to minimise lactic acidosis and acute kidney injury (AKI): SADMAN rules:
- S SGLT2 inhibitors
- A ACE inhibitors
- D Diuretics
- M Metformin
- A ARBs
- N NSAIDs
Otherwise see TREND-UK 2018
Type 2 diabetes
(Note: Ketosis is less common in insulin-requiring type 2 diabetes but DKA is possible in a subset)
Investigations:
Insulin requiring: Blood glucose every 4 hours or minimum 4 times daily?
Non-insulin requiring: Consider introducing temporary blood glucose monitoring during acute illness as clinically appropriate and monitor 4 hourly?
Management:
Advised:
Adequate fluid intake:
100-200 ml every hour
If blood glucose levels are normal or high use of sugar-free fluids
If blood glucose levels are low use sugary fluids:
- Pure fruit juice
- Ribena
- Milk
- Milk with drinking chocolate or Ovaltine
- Flat non-diet Coca-Cola or lemonade, but avoid carbonated drinks
If unable to keep fluids down consider antiemetic but have a low threshold for admission and IV fluids
If diarrhoea and vomiting use oral electrolyte rehydration sachets 150-300 mls per hour depending on hydration status
Carbohydrate intake:
To main normal meal pattern where possible
If unable to eat, replace meals with sugary drinks
Non-insulin requiring:
Gliclazide can be considered (or titrated) in short term, but consider advice from the diabetic team for temporary insulin
(Note: risk of hyperosmolar hyperglycaemic state (previously HONK))
If BGs:11-17: extra 2 units to each dose
17-22: extra 4 units to each dose
> 22: extra 6 units to each dose
If taking > 50 units TDD double adjustments above
≤ 4: reduce insulin dose by 10% and have hypo treatments available
Stopping regular medication to minimise lactic acidosis and acute kidney injury (AKI):SADMAN rules:
- S SGLT2 inhibitors
- A ACE inhibitors
- D Diuretics
- M Metformin
- A ARBs
- N NSAIDs
Hypoglycaemia (eg gastroenteritis):
Investigations:
Monitor BGs every 2 hours
Management:
Advised:
Small regular sips of sugar-containing fluids (see above in fluid intake)
If not tolerating much orally and BG low/normal reduce fast-acting insulin
If BG 10-14: give usual fast-acting insulin
If BG > 14: see above for extra insulin
If BG < 4 and unable to tolerate oral/buccal (eg glucogel) sugars: give glucagon:
- 2-17 years old (body weight < 25 kg) = 0.5mg glucagon IM
- 2-17 years old (body weight > 25 kg) or adult = 1mg glucagon IM
Resource(s):
Diabetes and Primary Care 2018
Information for patient/carer(s):
Appendix section of BSPED guidance document