Expansion
Never stop insulin, monitor more often, and maintain fluid and carbohydrate intake
Expansion
Illness raises cortisol, catecholamines, glucagon and growth hormone, causing insulin resistance and increased hepatic glucose output. Requirements therefore rise even when appetite falls.
Rules:
- Never stop insulin, even if not eating. Stopping it is the commonest cause of ketoacidosis in an unwell person with type 1 diabetes
- Monitor glucose more frequently, every 2 to 4 hours
- Check ketones if glucose is above 13 mmol/l or if unwell
- Maintain fluid intake, and take carbohydrate as drinks if solid food is not tolerated
- Have a plan for additional rapid-acting insulin based on ketone levels
- Seek help for persistent vomiting, ketones that will not clear, or drowsiness
Drugs to hold during dehydrating illness, sometimes remembered as the sick day rules for tablets: metformin (lactic acidosis risk), SGLT2 inhibitors (euglycaemic ketoacidosis), ACE inhibitors, angiotensin receptor blockers, diuretics and NSAIDs (acute kidney injury).
Euglycaemic ketoacidosis on SGLT2 inhibitors is a particular trap, since glucose may be near normal while ketones are high.