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Management of Intercurrent / Illness

Diabetes - Management of Intercurrent Illness


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Sick Day Rules for all those with Diabetes

To maintain normal glycaemia and avoid acute diabetic complications e.g. diabetic ketoacidosis and hypoglycaemia.

The management of illness in diabetes differs in Type 1and Type 2 Diabetes due to the risk of DKA in Type 1.

It must be remembered, however, that some patients previously classified as Type 2 may become so insulin deficient, due to progressive beta cell failure, that they can develop DKA. In general these patients tend to have been on insulin for a long time. Consider this possibility and test for ketones if in doubt. If present treat as Type 1.

Patients with Type 2 Diabetes presenting with HHS (Hyperosmolar Hyperglycaemic State) may need short term insulin rescue.

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Patient Advice if unwell

Never stop taking your tablets or insulin, Doses may need to be adjusted.

Test for urine or blood ketones if Type 1 diabetes

Increase home blood glucose monitoring to four times a day

Increase fluid intake to at least one glass of fluid every hour e.g. water, low sugar cordial drink, diet drink

Eat regular meals; if unable to eat then replace solid food with liquid carbohydrates e.g. fruit juice, soup, milk. yoghurts, milky puddings.

Those who have attended an educational programme (eg DAFNE/LIFE) can follow their individual dose management strategies.

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Advice to Healthcare Professionals

Treat cause of illness

Consider anti-emetic injection if nausea or vomiting. Provide with Dioralyte™or Rehidrat ® if necessary

Ensure patient has monitoring equipment for glucose (and ketones if Type 1).

If patients are taking oral medication and have elevated blood glucose levels,  consider increasing oral medication. Metformin may need to be temporarily stopped if vomiting. Sulphonylureas may need to be increased if hyperglycaemic, or reduced if hypoglycaemic. If advice needed, contact the diabetes specialist team.

If patients are taking exanetide or liraglutide, and are suffering from vomiting they may need to be advised to stop until vomiting has subsided. In addition if blood glucose levels are low, a reduction in their sulphonylurea may also be needed.

Patients who have completed a Type 1 education programme such as DAFNE or LIFE will have received specific advice as to how to manage illness and should follow these. If there is any concern about this in an individual case contact the Diabetes Specialist team for advice.

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Indications for Emergency Hospital Assessment

Large urinary ketones or blood ketones levels ≥ 3 mmol/l *

Persistent vomiting or diarrhoea, inability to swallow.

Ketoacidosis clinically obvious e.g. dehydration, abdominal pain, rapid/laboured breathing

If unwell refer according to clinical judgement

Glucose above 30mmol/l or recording 'HI' despite increase in tablets or insulin

If the patient is pregnant and has either positive urinary or blood ketones of any level

Severe or recurrent hypoglycaemia not manageable at home

* Consider taking specialist advice if concerned and low levels of ketones; above levels indicate severe illness.

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Dose Adjustment

Sick Day Rule Flow Chart

Insulin Treated Dose Adjustment Chart for Hyperglycaemia without Ketonuria or Symptoms


Dose Adjustment Advice for hyperglycaemia (for use with Sick Day Rule Flow Chart above)

It is difficult to give specific advice on insulin dose adjustment, in general the higher the total dose, the more insulin will need to be given.

Additional doses of insulin may need to be given, eg. a lunchtime dose if on bd insulin, or stat dose if on basal-bolus

Adjusting long acting insulin is not an adequate response to acute illness; rapid acting insulin may be necessary as well

Small doses of rapid acting insulin given every 2-4 hours according to monitoring results may be needed

In the absence of symptoms (or ketones) only take action if blood glucose levels are consistently elevated

If a response is not observed then specialist advice or referral should be arrange urgently.


Blood Glucose


BD biphasic e.g.Mixtard Analogue mixes


Basal bolus, QDS e.g.NovoRapid, Actrapid, Lispro, Humulin S, Glargine, Levemir Insulatard


Basal, ODe.g.Levemir, Glargine, Insulatard

  < 13mmol/L   ¬      continue normal doses     ® Check ketones; if present, increase 2 units      
  13 – 22 mmol/L  

Increase by 4 units


Increase by 4 units

  Increase by 4 units  


Above 22mmol/L  

Increase by 6 units


Increase by 6 units

  Increase by 6 units  







If blood sugar >30mmol/L, or remain persistently high after dose adjustment, contact Accident and Emergency.

Insulin resistant patients eg. total daily dose >100 units insulin, larger dose adjustments maybe needed.
Insulin sensitive patients eg. total daily dose <20 units insulin, muchsmaller dose adjustments may be required.

Remember to advise your patient to:


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Useful External Links & Resources
PDF File Diabetes UK | Coping with Diabetes when you are ill
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