diabetic sick days If we have well-controlled diabetes we are not at greater risk of acute disease than the rest of the population.
However, we will require special care during the illness period to avoid dehydration, hyperglycemia, hypoglycemia and ketosis.
Therefore, we need to have basic knowledge about each of these aspects.
In situations of illness, we must be able to have written norms of action and a telephone number to contact the diabetes team. In the event that with these guidelines we do not achieve control of diabetes or the disease, we would need to go to a hospital.
ONE OF THE MOST IMPORTANT ADVICE IS THAT NEVER, IN CASE OF ILLNESS, SHOULD WE STOP USING INSULIN.
Even in fasting states, insulin is still required to meet metabolic needs, which may be increased in acute illness.
In case we use continuous glucose monitoring (CGM) during the disease, we have to remember that certain systems are interfered with the measurement of glucose by certain substances such as paracetamol and that some do not have good precision in the hypo or hyperglycemic ranges. In these cases we must rely on capillary blood glucose determinations.
During illness we have to frequently monitor blood glucose (better to carry CGM) and ketone bodies in the blood. You should know that in the absence of insulin, fats begin to be consumed and ketone bodies appear, which can be the origin of nausea and abdominal pain and their accumulation can lead to a serious decompensation of diabetes diabetic ketoacidosis (DKA) and can reach even to diabetic hyperglycemic coma.
Blood glucose monitoring will be done very frequently using CGM or, failing that, with hourly or every 2 hour capillary blood glucose and ketonemia. It is considered that there are positive ketone bodies in the blood when their value is greater than 0.5 mmol / L.
We have to distinguish if the disease is associated with hypoglycemia (in general, this occurs with gastroenteritis or vomiting) or with hyperglycemia (in respiratory diseases, those that are accompanied by fever or require medications that raise blood glucose …) to see if it is necessary to increase or decrease the insulin dose.
In case of gastroenteritis we have to lower the insulin dose, since there is less carbohydrate intake due to vomiting or alteration of food absorption and therefore, we have a higher risk of hypoglycemia; even so, we never have to take insulin off as there is a risk of ketosis.
When there is fever or illness other than gastrointestinal, insulin needs tend to increase due to the release of stress hormones that oppose the action of insulin and its dose needs to be increased.
We must emphasize the specific aspects to take into account in terms of hydration and glycemic control.
IN REFERENCE TO INFECTIONS ASSOCIATED WITH HYPERGLYCAEMIA, IT IS NECESSARY TO SEE WHETHER KETONIC BODIES EXIST OR NOT, SINCE OUR PERFORMANCE IS GOING TO BE DIFFERENT IN THIS CASE.
to. Hyperglycemia with positive ketone bodies
We must provide fluids without carbohydrates (CH) if the blood glucose is higher than 250-300 mg / dl. When it is lower than this figure we have to start taking fast-absorbing HC but always administering insulin.
To correct hyperglycemia, we need to administer insulin supplements with rapid-acting analogues according to the Correction Factor (sensitivity index), used as a glycemic target of 100-120 mg / dl (higher if we start with very high blood glucose levels), remembering that it is not we must lower blood glucose more than 200 mg / dl in 2 hours.
When there is ketosis, as insulin resistance is higher, we can increase the calculated dose by 10-20%.
The insulin dose must be repeated every 2-3 hours until the ketone bodies disappear, always providing carbohydrates.
If ketone bodies persist and blood glucose is below 140 mg / dl, we have to increase the intake of CH (since both CH and insulin are needed to metabolize ketone bodies).
b. Hyperglycemia without the presence of ketone bodies
We have to administer supplementary doses of insulin: rapid-acting analogues (AAR) every two or three hours, using the formula already described. Sometimes it is convenient to increase the basal level on the pump or long-acting insulin by around 20% in the case of disease causing sustained hyperglycemia and increase boluses before ingestion by around 10-20% and assess the response.
c. Hypoglycemia with or without ketosis (in gastroenteritis …)
It is necessary to provide easily digestible liquids with fast-absorbing HC: juices, skimmed milk for example … etc. and decrease the insulin dose in case of ingestion by 20 to 50%. In this case, never give fluids without CH
In this period, ketone bodies must be assessed frequently to see if the carbohydrate intake is sufficient.
In the face of hypoglycemia, that is, a blood glucose level below 70 mg / dl, with nausea or rejection of food that we cannot overcome orally, an alternative is to use small doses of glucagon, the so-called “glucagon minidose regimen”, which It can be repeated at the hour if necessary.