Sick day plan for type 2 diabetes
| What to consider | What to do |
|---|---|
| Be prepared for sick days | Ensure you know how to use your glucose monitor and have enough strips to monitor blood glucose for about a week – this might need to be as much as 12 tests per day. Check the expiry dates of the strips. Check that you have enough medications, including insulin. |
| When to start your plan | Start to follow this plan: – if you are feeling unwell – even if your glucose levels are normal; or – if your glucose levels are above 15 mmol/L two times in a row; or – if your glucose levels fall below 4 mmol/L |
| Blood glucose monitoring | If you are not already monitoring your blood glucose levels, start monitoring them when you start following this plan |
| What to do if your support person is not available | If you can manage ok, then follow the plan. If you feel too unwell to manage your diabetes or need any assistance, please call your doctor or diabetes team |
| Low blood glucose levels (hypoglycaemia) | If your blood glucose is below 4 mmol/L: – Take 15 grams of glucose (eg 5–6 large glucose jelly beans) – After 15 minutes, retest your blood glucose. If it is still below 4 mmol/L, take another 15 grams of glucose – After another 15 minutes, retest your blood glucose. – If it is still below 4 mmol/L, call your GP or dial 000. – If your blood glucose levels have increased to above 4 mmol/L, eat some additional slow-acting carbohydrate, such as a slice of bread, a dry biscuit or a glass of milk. This may be especially needed if you can’t tolerate your usual food, or can’t have a normal meal within 20 minutes. If your blood glucose levels stay above 4 mmol/L, keep testing them every 2–4 hours for as long as you are unwell. Make an appointment with your GP or diabetes team to discuss the hypoglycaemia and decide whether you need any adjustments to your diabetes management Note: Do not drive if your blood glucose levels are below 5 mmol/L |
| High blood glucose levels (hyperglycaemia) | If your blood glucose levels are above 15 mmol/L, start writing them down so you can share them with your doctor If you are taking insulin, follow the instructions below for ‘If you are taking insulin’ Please call your doctor or call 000 if you experience any of the following: – your blood glucose levels do not go down to less than 15 mmol/L within 24 hours – you feel abdominal pain – you feel drowsy or confused – you have difficulty breathing |
| Blood ketone monitoring | Start monitoring your blood ketone levels if you are instructed to by your health team, or if: – your glucose rises above 15 mmol/L and stays there for 4 hours – you are taking [Prescriber insert as appropriate name of SGLT2 inhibitor or insulin – see note 1 above], or – you have abdominal pain, feel drowsy or confused, or have difficulty breathing If your blood ketone levels are above 1.5, notify your doctor or diabetes team |
| If you are taking diabetes tablets or non-injectable medicines | DO NOT STOP TAKING ANY MEDICATION unless advised as below If you have diarrhoea or vomiting, or cannot tolerate fluids, your GP might advise you to STOP taking: [Prescriber insert as appropriate: metformin, and/or GLP-1 RA , SGLT-2 inhibitor or sulfonylurea – see note 2] If you can keep food and drink down, you may not need to stop taking your medication If you are taking [Prescriber insert as appropriate: SGLT-2 inhibitor – see note 2], start monitoring your blood ketone levels, as instructed by your health team (see ‘Blood ketone monitoring’, above) |
| If you are taking insulin | DO NOT STOP TAKING INSULIN unless advised If you are unwell, you might need to change your insulin dose. Changes to insulin require careful advice from your GP or health team. Make sure you understand the steps you need to take, and talk to your GP or diabetes team if you aren’t sure.Monitor your blood glucose levels at least every 2 hours while you are unwell, and refer to ‘Low blood glucose’ and ‘High blood glucose’, above. If your blood glucose levels fall below 4 mmol/L, follow the instructions given under ‘Low blood glucose (hypoglycaemia)’. If your glucose levels rise above 15 mmol/L and you are taking [Prescriber insert as appropriate: basal insulin – see note 3], do the following: — temporarily increase your dose by 10%. For example, if you normally take 40 units, increase to 44 units once a day. — If your blood glucose levels go back to normal, start taking your usual dose again — If you are also taking tablets, see ‘If you are taking diabetes tablets or non-injectable medicines on non-insulin diabetes medicines’, above. If your glucose is still above 15 mmol/L after 4 hours, do the following: — start blood ketone monitoring (see above). If your blood ketone levels are above 1.5, notify your doctor or diabetes team. — You may also need to take extra, rapid-acting insulin, called [Prescriber insert name]: —— Start with a single injection of [Prescriber insert DOSE: usual dose is 2–4 units only – see note 3] —— Keep monitoring your blood glucose every 2 hours — After 4 hours – if your blood glucose is still above 15 mmol/L, take another extra dose, following steps 1 and 2 above. – After another 4 hours – if there is still no effect on lowering glucose, call your |
| Food and fluids | Make sure you stay hydrated while you’re unwell, by drinking 250 mls of fluid every hour. — If your blood glucose is above 15 mmol/L, you should drink water or drinks that don’t contain carbohydrate — if your blood glucose less than 15 mmol/L, you can drink any fluids, including those that contain sugar Try to keep eating some carbohydrate. If you have nausea or vomiting, try soup (not broths) and light or softer foods |
| Recovery | Once you start to recover, if your blood glucose is BELOW 15 mmol/L and consistently ABOVE 4 mmol/L, and you are eating and drinking well, you may start taking your medications again if you have stopped them Call your GP, credentialled diabetes educator and/or nurse practitioner to schedule a review to discuss your illness and plan |
| Seeking help When to go to the emergency department | Call your GP if: – you’re too unwell to monitor your glucose, or can’t keep fluids down – your blood glucose levels stay above 15 mmol/L for more than 24 hours – your blood glucose levels stay above 15 mmol/L despite two extra rapid-acting insulin doses – you can’t keep your blood glucose levels above 4 mmol/L – you blood ketone levels are >1.5mmol/L – you feel drowsy, confused, have difficulty breathing, or have severe abdominal pain – you have persistent vomiting, especially if you vomit a lot for more than 2–4 hours If you can’t contact your doctor, or you feel frightened or unsure, go to an emergency department or call 000 |
Notes
- Consider advising all patients using sodium glucose co-transporter 2 (SGLT2) inhibitors or insulin to monitor blood ketone levels during intercurrent illness.
- DPP-4 inhibitors are usually well tolerated during intercurrent illness. Note that sulfonylureas may aggravate or precipitate hypoglycaemia in people with intercurrent illness. Use of corticosteroids may precipitate hyperglycaemic emergencies even in those people with diabetes managed with diet alone.
- Adjusting doses of the following basal insulins may not result in similar changes in glucose management during intercurrent illness, due to the prolonged half-life: insulin glargine U300 (Toujeo®) and degludec containing co-formulated insulin (Ryzodeg®). If prescribing the above or multiple daily premixed insulin, consider discussing dose-adjustments for intercurrent illness with a specialist diabetes team.