Northumbria Healthcare NHS Foundation Trust Sick Day Rules for People with Diabetes Issued by the Diabetes Service
www.northumbria.nhs.uk Background: How illness may affect your diabetes 3 What to do for Type 1 Diabetes 5 What to do for Type 2 Diabetes 9 Working out your extra Insulin doses Table 12 Eating & Drinking 12 Notes 2
If you have a cold, flu or any other illness, here are a few simple rules you should always remember that will help you cope Background Illness and infections cause your body to be more stressed. When you have diabetes your blood glucose (sugar) levels often rise during illness especially if you have a fever (high temperature). The kind of illnesses most likely to have an effect on your blood glucose are, the common cold or flu, sore throats, urine infections, bronchitis or chest infections, stomach upsets and diarrhoea, skin abscesses. It is important for you and anyone who may help you when you are ill to learn what to do, because when the blood glucose levels go up this can make it more difficult to keep your diabetes under control. Extra insulin is sometimes necessary, so you need to know how to manage the sick day rules. Your blood glucose may rise even if you are unable to eat your normal food or drink. Contact your GP or clinic: If you are not sure what to do If you are persistently vomiting (not able to hold down any food or drink for more than 6 hours), as you can quickly become very dehydrated If your blood glucose stays high 3
Contacts for advice GP Practice Tel:... Diabetes Team Tel:... Out of Hours Tel:... Other: Tel:... 4
DAFNE: For people using the DAFNE (Dose Adjustment For Normal Eating) regime use the DAFNE sick day rule guidelines Type 1 Diabetes Important Points Your Insulin should never be stopped. You may need an increased insulin dose and/or additional doses of fast acting insulin may be necessary to bring down the blood sugars (for example Novorapid insulin 4 hourly) see insulin adjustment table. Blood glucose levels should be checked at least every 2-4 hours. If you are worried you might go hypo sip sugary drinks, or suck boiled sweets or glucose tablets Try and drink clear sugar free fluids to avoid dehydration Your food can be taken in alternative forms (see page 12) What blood glucose level should you aim for when you re ill? Aim: Blood glucose target between 6-10mmol/L Testing: If your blood glucose levels stays above 10mmol/L follow the guidelines for increasing your insulin. Extra blood glucose testing will be necessary. You will need to test every 2-4 hours and especially every 2 hours if your blood glucose is high (over 15mmol and if you have ketones in your urine, or you are using a quick acting analogue insulin (Novorapid or Humalog), because this insulin will only last in your body for a short period of time. 5
Ketones: Everyone with Type 1 diabetes should have ketostix at home for use during illness and other times when the blood glucose levels are high. You can test for ketones with a simple urine test. The test strips (Ketostix) are available on prescription from your GP. Some blood glucose meters can also test for ketones with a different test strip available on prescription. Having ketones at levels of moderate or large amounts will usually indicate that your blood glucose levels are high and you need extra insulin. Ketoacidosis (also known as DKA): When you have Type 1 diabetes you need insulin in your body in the correct amounts all of the time. The extra demands of illness mean your need for insulin will increase, even if you are not able to eat. If there is not enough glucose getting into the cells of the body, fat stores are used as an alternative source of energy. Because the body can t burn up fat very efficiently, by-products known as ketones are given off. Ketones are acids and therefore make the blood acidic. Not getting enough insulin at this time and if it is left untreated can result in ketoacidosis, where you can become seriously unwell. If it doesn t respond to treatment at home within 6 hours it may need to be treated in hospital. Symptoms of ketoacidosis are: Blood glucose over 15 mmol/l Ketones in your urine Thirst Passing large amounts of urine (this leads to dehydration) Tiredness Seek urgent help if you have: Vomiting Rapid breathing Reduced level of consciousness (drowsiness) 6
Insulin adjustment during illness for Type 1 diabetes Remember - never stop taking your insulin Types of quick acting insulin: Analogue Insulin Soluble Insulin Novorapid (Aspart) Humalog (Lispro) Humulin S Actrapid (only available in 10ml vials for use with insulin syringes) If your blood glucose is between 10mmol/L 13mmol/L Increase your usual insulin by 10% Check blood glucose every 4 hours. If no improvement after 24 hours increase by a further 10% If no improvement after 48 hours follow the guidelines below. If your blood glucose is above 13mmol/L Blood glucose is over 13mmol/L or has not responded following an increase in insulin Increase usual insulin by 10% and give extra dose of quick acting insulin (approximately 10% of total daily insulin) repeat every 2 to 4 hours Increase your insulin and test urine for ketones If the result is moderate or large amount, test every two hours until they reduce Try to drink at least 2 litres a day (5 pints) of sugar free liquids 7
In case of severe illness 10% of my usual total daily insulin dose = units (use the table on page 12 to work this out) 20% of my usual total daily insulin dose = units (use the table on page 12 to work this out) Your blood glucose is over 15mmol/L and you have moderate or large amount of ketones. Continue to take your usual insulin, and follow the guide for extra quick acting insulin: Extra quick acting insulin dose: if blood glucose is over 15mmol/L you may need to give a larger dose. Consider giving 20% of total daily insulin (use the table on page 11 to work this out) and Test your blood glucose and test your urine for ketones every 2 hours and repeat extra quick acting insulin doses until blood glucose levels reduce to below 15mmol/L and the ketone level reduces. Try to drink at least 2 litres of sugar free fluids over 6 hours If blood glucose is not controlled below 15mmol/L after 48 hours you may need to contact GP/Specialist Service for advice. Remember to reduce your insulin back to your usual dose when your blood sugar is back to your normal levels 8
Type 2 Diabetes Recognising when your blood glucose (sugar) is high: When your blood glucose is high you usually get the following symptoms Thirst/dry mouth Passing large amounts or urine (this can lead to dehydration) Tiredness Weight Loss Type 2 Diabetes on tablets: Try and keep taking your medication Metformin only If you are taking Metformin tablets you may be using urine testing (for glucose) to monitor your diabetes. This form of testing will only give you a guide but could alert you to possible high blood glucose levels if there is large amounts of glucose passing into your urine, more than ++. If you are taking Metformin tablets, you may need to temporarily stop these tablets. This is usually if you have a severe infection or are becoming dehydrated and your GP or Diabetes Team will advise you. If this is necessary you will need a different treatment for your diabetes until you can re-start your Metformin tablets. Metformin and a Sulphonylurea or Sulphonylurea only The most commonly used Sulphonylurea tablets are called Gliclazide. You may have been provided with blood glucose testing equipment mainly to be able to confirm that your blood glucose has gone too low (hypoglycaemia) and to routinely monitor your diabetes, but you may not test very often. In illness your blood glucose usually rises. Use your test results as a guide and aim to keep your blood glucose between 6 and 10mmol/L. You will need to test more frequently, at least twice a day. 9
You may need to have a temporary increase in your tablets to keep your blood glucose controlled until you are better. The maximum dose of tablets is: Metformin (Glucophage) 500mgs 1g two/three times daily Metformin (Glucophage) 850mg one tablet three times daily Metformin SR (Glucophage SR) 2g once daily, or 1g twice daily 500mgs Gliclazide 80mgs two tablets (160mgs) twice daily Type 2 Diabetes and Insulin People who have Type 2 diabetes on insulin must be provided with the equipment to test their own blood glucose levels at home. Aim to keep your blood glucose levels between 6 and 10mmol/L. If when you are ill it stays above 10mmol/L follow the guidelines for increasing your insulin. Extra blood glucose testing will often be necessary. You will need to test every 4 hours and especially if your blood glucose is high (over 15mmol/L) Ketones: If your blood glucose gets too high, (over 15mmol/L then you may have to have a urine test for ketones. People with Type 2 diabetes are not routinely prescribed Ketostix to test for themselves at home. Insulin and Tablets: If you are taking Metformin tablets, you may need to temporarily stop these tablets. This is usually if you have a severe infection or are becoming dehydrated and your GP or Diabetes Team will advise you. If you are taking a sulphonylurea tablet (Gliclazide) continue as usual. If you are on once daily insulin and need to change to twice daily insulin, do this by halving your usual once daily insulin dose: take your AM dose with breakfast and PM dose with evening meal. You will be advised by your GP or Specialist Diabetes Team. 10
Insulin dose adjustment during illness for Type 2 diabetes If your blood glucose is between 10mmol/L 15mmol/L Increase insulin by 20% Check blood glucose every 4 hours if no improvement after 24 hours Increase insulin by a further 10%. If no improvement after 48 hours follow the guidelines below If your blood glucose is above 15mmol/L Blood glucose is over 15mmol/L or has not responded following an increase in insulin Increase your usual insulin by 20% and Give extra dose of quick acting insulin (approximately 10% of total daily insulin) repeat every 4 hours If your blood glucose not below 15mmol/L after 24 hours increase usual insulin by a further 10% Quick acting insulin is Novorapid (Aspart), Humalog (Lispro) or Humulin S insulin. If not controlled below 15mmol/L after 48 hours consider making contact for advice Remember to reduce your insulin back to your usual dose when blood sugar is back to your normal levels 10% of my usual total daily insulin dose = units (use the table on page 11 to work this out) 20% of my usual total daily insulin dose = units (use the table on page 11 to work this out) 11
Table of 10% and 20% insulin units My usual insulin dose is: 10% = 20% = 1-14 units or less 1 unit 2 units 15-24 units 2 units 4 units 25-34 units 3 units 6 units 35-44 units 4 units 8 units 45-54 units 5 units 10 units 55-64 units 6 units 12 units 65-74 units 7 units 14 units 75-100 units 8 units 16 units Eating and Drinking Here are some food and drinks that can be useful alternatives. If you are unable to eat your normal diet, then you can replace food with small frequent amounts of the following: Lucozade 50ml Natural unsweetened fruit juice 100ml Ordinary Cola or Lemonade 100ml Milk 200ml Tomato Soup 200ml Complan 1 level teaspoon ordinary Ribena 2 tablespoons Horlicks / Ovaltine 2 heaped teaspoons Ice Cream 2 oz (approx. 80g) Travel It is always helpful to take with you something to treat a high temperature or diarrhoea in case you become sick when you are away from home. Ask your diabetes team about more information when travelling. 12
13
14
15
PIN 451/V3 Review date: August 2017