Zoning in on Sick Day Management: Practical Tips, Strategies, and Advice

By Dr. Francine Kaufman

Pediatric endocrinologist Dr. Fran Kaufman shares tips for managing illness and diabetes: make a sick day plan, have supplies on hand, log your data, modify your insulin doses, and call your healthcare team. 

Everyone with diabetes who takes insulin needs to have a sick day plan. This is something you develop with your healthcare professional to help you manage the high and low sugar levels that can be associated with an illness. The following advice applies to people with type 1 diabetes and people with type 2 diabetes who take insulin – the advice may be different if you have type 2 diabetes and do not take insulin.

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When you get sick, you are at risk of becoming dehydrated from poor intake or from excessive loss of fluids due to nausea, vomiting, diarrhea, and fever (your body may lose more water when you have a high temperature). In addition, dehydration is common in diabetes because high glucose levels (above 180-200 mg/dL) cause sugar to enter your urine, dragging an excess amount of fluid with it. Illness also puts you at risk of developing ketones, which when coupled with high glucose levels can lead to diabetic ketoacidosis (DKA), a very serious condition. How do you know if you have ketones? Good question, click here!

The purpose of your sick day plan is to try to keep your glucose levels in a safe range – to avoid dehydration and to prevent ketones from rising to a dangerous level. When you get sick, you should contact your healthcare team to describe your symptoms, determine if they want to evaluate you or send you to a lab (for testing), and most important, to share the numbers that you will collect as you fill in your sick day log (more on this below). It is possible that no matter what you do, you might need to go to an emergency department or be hospitalized – but acting quickly, obtaining the right data, and doing your best to manage your glucose and hydration will minimize risks.

So what illnesses are we talking about? It turns out just about any common bacterial or viral infection – such as the flu (influenza), a cold (upper respiratory virus), tonsillitis, strep throat, an ear infection, stomach flu (gastroenteritis), a bladder infection, and even a skin infection, such as an abscess – can interfere with your diabetes management. However, right now, the greatest concern is COVID-19. An infection with COVID-19 can lead to very high glucose and ketone levels, putting someone at risk for DKA. Acting quickly to start your sick day plan, even if you end up needing to be hospitalized, is important.

When you get sick, your body needs energy to fight the infection and repair damaged tissue. The infections listed above, particularly those that lead to vomiting, diarrhea, fever, and dehydration, cause your body to release certain hormones (called stress or counterregulatory hormones) that tell your liver to release stored glucose and tell your fat cells to release free fatty acids that form ketones. In someone without diabetes, the body releases more insulin to control the rise in glucose and ketones; because you have diabetes, you have to take additional insulin to manage the high glucose and ketone levels. You want to get your sugar levels between 100-180 mg/dL. Blood sugars below 180 mg/dL will prevent excess urination that can dehydrate your body. Staying above 100 mg/dL helps keep you from dipping too low and risking severe hypoglycemia.

If your glucose level is above 180 mg/dL, you need to consider increasing basal insulin doses, using an increase in basal insulin with the temp basal feature on your insulin pump, or giving repeated corrections of bolus insulin with a syringe, pen or pump. Usually, correction doses should not be given more often than every two to three hours to avoid “stacking” insulin, which could lead to low blood sugars. By having a plan for illnesses that starts your modified care early and by keeping in touch with your healthcare team, you are more likely to keep your glucose values in the 100-180 mg/dL range.

But you also have to be concerned about hypoglycemia. Low sugar occurs, particularly in children and the elderly, if the illness affects calorie and carbohydrate intake by decreasing appetite or by causing vomiting or diarrhea. Although low glucose is usually considered to be less than 70 mg/dL, during illness there is concern if glucose levels are below 100 mg/dL. If your infection or illness leads to low glucose levels, reducing basal insulin and not taking bolus insulin doses should be considered. If suspension of insulin is required, you should not suspend or delay taking the next dose of basal insulin for more than 60 minutes, because this increases your risk of developing ketones. Start sipping a sugar-containing drink, one tablespoon at a time. If hypoglycemia continues and you cannot make it better by ingesting sugar, consider the administration of low-dose glucagon. Low-dose glucagon can increase glucose level by 50-200 mg/dL in 30 minutes. To learn about whether low-dose glucagon is right for you, and at what dose, talk with your healthcare team.

To follow what is happening in your body, it helps to start a log of your glucose levels, ketones, fluid intake, and insulin doses. This sick log can be shared with your health care team. It should show improvement from one time period to the next (see below). Note: the biggest concern is vomiting; if you vomit more than twice in a time period or across two time periods, call your healthcare team.

The log shows only two days, because you should be better after 24 hours and completely on the mend after 48 hours. If you are not getting better, call your healthcare team.

Table

Image source: diaTribe

Here’s how to keep track (and why to keep track!) of these important numbers:

1. Glucose Levels: Check glucose levels every 1-2 hours. You may have to change this and check your glucose every 30 minutes if your levels are changing quickly. CGM trend data should be looked at every 10-15 minutes. Watch for rapid changes by looking at numbers and arrows. The goal is to keep your glucose between 100-180 mg/dL and without wide swings in values.

2. Ketone Levels: Urine ketones are often detected using a urine ketone strip. A small patch on the strip changes color depending on your level of ketones, representing negative, small, moderate, large and very large levels of ketones. Moderate, large, and very large levels are of concern. Ketones can also be measured with a fingerstick and a special ketone meter. The readings for blood ketones are more accurate and range from 0.0 to 3.0 mmol/L or greater. Blood ketone levels below 0.6 mmol/L are considered normal. Between 0.6 and 1.5 mmol/L ketones are high and show that your fat has broken down to form excess ketones. This puts you at risk of DKA if glucose levels are also elevated. Ketone levels above 1.5 mmol/L are serious, and you should contact your healthcare professional. Signs of elevated ketones:

  • Nausea and vomiting (which may also be present because of the infection)
  • Shortness of breath and labored breathing (your body is trying to eliminate the ketones through your breath so you can also smell them, they make your breath smell fruity)
  • Weakness
  • Altered level of consciousness and trouble staying awake (this is most concerning; call your healthcare professional immediately if this is happening)

Ketones should be tested at the onset of an illness and then every four hours.  If ketone and glucose levels are both elevated, your healthcare team might advise you to increase correction insulin doses further, by an additional 10-15%. If ketone levels are high and glucose levels are not high (less than 150 mg/dL), oral glucose and some insulin – reduced by about 50% – will help clear your ketones. Drinking water will also help reduce ketones as they are removed in the urine. To learn more about ketones, including what they are and how to measure them, click here.

3. Temperature: High fever can help show the severity of your illness, particularly if it is persistent.  We have learned that COVID-19 is associated with persistent high fever. Use the log sheet to document any medications you take to lower fever so that you can report this to your healthcare team.

4. Fluid Intake, with and without Sugar: Consuming liquids is critical if there is risk of dehydration. Fluids with sugar should be taken if glucose levels are between 100-150 mg/dL, and fluids without sugar should be taken if glucose levels are between 150-180 mg/dL. If you have vomited, wait 30-60 minutes before trying to drink, and then start with teaspoons of water or ice chips, progressing to tablespoons and ounces. The goal is to retain 4-6 ounces of fluids (or 2-4 ounces for young children) every 30-60 minutes until you can drink without risk of vomiting and as your thirst dictates. Food is much less important after vomiting; don’t try to eat food until you are on the mend.

5. Urination: Noting frequency and amount (small, medium, or large) is important to understand the ongoing risk of dehydration. As glucose levels reach the target of 100-180 mg/dL, you should see a decrease in both frequency and amount of urination, as well as less dehydration.

6. Vomiting, Diarrhea and Dehydration:  Vomiting and diarrhea can lead to dehydration. The signs of dehydration include dry mouth, sunken eyes, weakness, loose skin, rapid heart rate, and low blood pressure. Vomiting is also of great concern because it occurs not only from the illness, but as a result of DKA. That’s why vomiting that occurs throughout one time period or spans two time periods in your log means it is time to call your healthcare professional.  However, if you feel weak after vomiting only once or twice, it is always better to call earlier than later.

7.  Insulin, Amount and Time: One of the most important things to remember is that during an illness, you still need to take insulin. Even if you are not eating or drinking at the beginning, you need to have insulin in your body. Insulin allows sugar to enter your body’s cells to be used for energy, and you need more energy to fight off an illness. Insulin also reduces ketone formation and stops excess urination by lowering glucose levels. If you have high glucose, you might need 25-50% more insulin than you usually take, due to insulin resistance created by the extra stress or counterregulatory hormones in your body. If you have low glucose, you might need to take 25-50% less insulin than you usually take, but you still need some basal or background insulin on board.

8. Medications: At the beginning of an illness, you should consider calling your healthcare team to determine if you should avoid taking any of your routine medications while sick. This includes glucose-lowering pills or injections, such as SGLT-2 and GLP-1 drugs, or medications for blood pressure and cholesterol. In addition, it is important to write down any medications you take (name, dosage, time) to treat fever, vomiting, diarrhea, or other symptoms of your illness. Anti-vomiting medications may be helpful but should only be taken after discussing with your healthcare professional.

Key Messages:  

  • Know your sick day plan before you become sick.
  • Have supplies on hand. These include supplies to measure glucose, a way to measure ketones, a thermometer, sugar-containing fluids, glucagon, extra-rapid (or short) acting insulin, and medication to treat fever. Discuss with your healthcare team whether you should have medication for diarrhea and vomiting on hand.
  • Have all the contact information for your healthcare team available, and call them sooner rather than later.
  • Before you call your healthcare team, have the data listed on your log sheet written down, plus your symptoms.
  • Take insulin at modified doses to address both high and low glucose levels. You still need to have some insulin in your body, even if you are not eating.
  • Let someone help you while you are ill. It is too big a job to be done alone.

About Fran

Dr. Fran Kaufman is the Chief Medical Officer of Senseonics, Inc. She is a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications at the University of Southern California.

Source: diabetesdaily.com

Hypoglycemia Preparedness: How to Know Before You Go Low

This content originally appeared on diaTribe. Republished with permission.

By Lorena Bergstrom

A new awareness campaign helps people with diabetes recognize and plan for low blood sugar with emergency toolkits, discussion prompts, journaling, and a support network  

Low blood sugar can be a scary thing – it often sneaks up when people least expect it, quickly shifting from a minor annoyance to a potentially dangerous situation. In fact, a Canadian study found that people with diabetes (type 1 and type 2) experience severe hypoglycemia an average of 2.5 times each year. While type 2 diabetes typically presents a lower hypoglycemic risk than type 1, insulin and oral medications can still cause low blood sugar. However, you can take many steps to protect yourself.

We spoke with endocrinologist Dr. Gregory Dodell (with Mount Sinai in New York) and singer Crystal Bowersox about Lilly’s new Know Before the Low campaign, an important initiative to raise awareness about hypoglycemia. Bowersox and Dr. Dodell hope this program will empower people with diabetes to recognize signs of low blood sugar, start conversations with their peers, and prepare for emergencies before they happen.

Dodell

Image source: diaTribe

Know Before the Low offers information about managing hypoglycemia; it includes a chart of physical and cognitive symptoms, a tip list for emergency planning, and a guide for building a support network. Dr. Dodell said that unfortunately most diabetes literature focuses on controlling high blood sugar – even though low blood sugar can be more dangerous. He said that the campaign aims to address this information gap by “helping people and healthcare professionals talk about low blood sugar and prevent future episodes.”

To start, every person with diabetes should build an emergency toolkit, including:

  • Glucose tablets or sugary snacks
  • Glucagon – read about emergency nasal glucagon (Baqsimi) and ready-to-use autoinjector pens (Gvoke)
  • Glucose monitor (continuous glucose monitor or fingerstick blood glucose meter)
  • Emergency contact information

Bowersox makes her emergency pouch easily accessible to her friends and family: “My family, including my 11-year-old son, knows what to do if I have a hypoglycemic episode or emergency. I think it’s important for an individual’s entire support network to be aware of this.” Of course, it may seem inconvenient to carry around an entire toolkit when going out, but many of the new glucagons (like Gvoke and Baqsimi) are much more portable and easier to use than the glucagon previously available.

Keep in mind that for many people with diabetes, nighttime is both the most dangerous and the most common time to experience hypoglycemia. Dr. Dodell shared some useful advice: “If you see a downward trend before bed, you should eat a snack. It’s better to wake up high and correct during the day than have a low blood sugar episode overnight, which could cause many more complications and inconveniences. It’s also important for people with diabetes to know the triggers that can cause lows at night.” In short: check blood glucose before bed, play it safe, and know your risk factors. Additionally, daily routines have changed during COVID-19; you may be eating different foods, exercising more or less, and experiencing higher stress. All these factors may affect your blood sugar, especially at night.

Everyone’s body is different, but common risk factors for hypoglycemia include:

  • Exercise
  • Too much insulin
  • Fasting or low carbohydrate intake
  • Alcohol
  • Medications
  • Stress
  • Hormonal fluctuations
  • Illness

For a full list, check out Adam Brown and diaTribe’s 42 factors that affect blood glucose from his book Bright Spots & Landmines.

Hypoglycemia is different for everyone, so it is essential to be aware of your own body. Try to observe the symptoms you experience, and make note of potential triggers. Bowersox recommended keeping track of patterns: “Keeping a log or journal of things such as physical or emotional activity and comparing it to your blood sugar data could be a good way to see if there are trends that are causing you to go low. Ultimately, it’s important to share that information with your support network.” Know yourself – there are many factors that can lead to hypoglycemia, so it’s important to learn your own patterns of low blood sugar so that you can avoid these experiences.

KBTL

Image source: diaTribe

Perhaps the most critical part of Know Before the Low is its emphasis on connecting with your support network – family, friends, coworkers, teachers, and others. Bowersox said that she once had to ask her audience for candy to raise her blood sugar; fans were supportive and thanked her for raising awareness about diabetes. However, it can sometimes be difficult or uncomfortable to start conversations about diabetes and hypoglycemia with the people around us. Dr. Dodell explained that keeping the dialogue casual yet informative can be an opportunity to teach people something new: “You’re not putting a burden on them, but just explaining how diabetes affects your life. By broaching the topic casually, you can treat the conversation as more of a heads up than bestowing a responsibility. Just make sure to explain that you are carefully managing your diabetes, but there is a chance of an emergency. Not everyone has met someone with diabetes, but just explaining it and educating them can be a great preventive step.”

By sharing information about hypoglycemia signs, symptoms, and treatments, you can empower your peers to step in during an emergency. As Bowersox said, “Knowledge is power! When your network has information, they are empowered to help you, especially with low blood sugar. When I travel, my quality of life is improved by just educating and speaking up. Practice with your mirror, practice with your pet, but make sure your support network is there for you.”

As this project raises awareness of hypoglycemia, we hope it encourages people with diabetes, their healthcare professionals, and their support networks to engage in valuable discussions. As Dr. Dodell so perfectly concluded, “This campaign is one of the first to address the dangers of hypoglycemia. It is groundbreaking, and allows people to get needed resources. Diabetes experts and endocrinologists know that high blood sugar can sometimes be better than low blood sugar.”

For more information, read diaTribe’s article on hypoglycemia unawareness.

Source: diabetesdaily.com

Diabetes Cheatsheet for Family and Friends

This content originally appeared on Blood Sugar Trampoline. Republished with permission. Do you struggle to explain your type 1 diabetes to your friends and family? Or maybe you are just tired of explaining it again and again, and again? Here is a quick rundown of some of the basics that you can share with your […]
Source: diabetesdaily.com

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