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

Parenting, Working, and Diabetes During the Coronavirus Pandemic

This content originally appeared on diaTribe. Republished with permission.

By Cheryl Alkon

For some, school cancelations and working from home have added stress that can make diabetes management even more difficult. Here are the perspectives and strategies of several parents who are navigating this environment

With COVID-19 spreading through the United States, every state in the country has closed public and private elementary, middle and high schools. As a result, many of us are living and working at home full time with our kids.

How are you overseeing your diabetes during this time? Several parents with diabetes shared what they’re doing, how they’re managing, and their best advice.

Go Easy on Yourself

Ellen Sheng, of New Jersey, pulled her 11- and 6-year old sons out of their schools three days before the schools closed on March 13 for at least a month. While the fifth grader had online instruction the day after the schools shut, the younger child had a week off from any school-based learning. Sheng’s husband is also working from home during this period.

“I’ve been trying to come up with lessons and activities while also juggling work deadlines,” says Sheng, a financial journalist. “Between the lack of exercise (I usually go to the gym), and all the stress, my numbers have been trending high. I activated my ‘stress’ basal setting on my insulin pump, which is usually reserved for that time of the month or visits from my mom. I’ve still had to do a lot of corrections. I guess I need a special ‘pandemic’ basal setting.”

Sheng suggests focusing on what you can to help ease into what is admittedly a historical and unprecedented period in time. “It’s only been a few days with everyone home, so we are still figuring things out,” she says. “I’ve been focused on getting enough sleep, meditating, carving out time for exercise such as walks with the kids and doing a short high-intensity interval training workout outdoors with my husband, and watching some comedy. I’m also trying to keep to my usual diet instead of stress eating, which I’m prone to do. It’s starting to help: I went back to my usual basal setting today [after about a week of kids being home].”

Take It One Day at a Time, and Be Realistic

Focus on what you can control, advises Theresa Hastings in Denver, Colorado. Her kids are 9 and 6 and have been home since March 13. Overseeing the stress of the pandemic, unexpected homeschooling for her kids with learning differences (autism and ADHD), stocking the pantry, cancelled vacations, and ensuring she has enough diabetes medications on hand, “has taken me from great diabetes management to less than optimal management,” she said. “The entire thing is stressful from top to bottom.”

For supervising her kids’ online learning, Hastings broke the process down into manageable steps. She took the school’s lessons and divided them into daily checklists. That way, her kids can see exactly what they need to do, and once they finish, “know they can play as if it were the weekend,” she says. To work around her son’s hatred of journal writing, which is expected in school but causes a battle and tears at home (and makes Hastings’ blood sugars skyrocket), “I adapted that into something my son would enjoy, which is writing letters to friends and family on a topic with three things about that topic. I communicated with the teacher to make sure my change met her expectations.” The adaptation has worked both for her son and his teacher, and has helped Hastings keep her glucose levels stable.

Making things reasonable helps lower stress levels and contributes to more manageable blood sugars. “While I’d love to do so many amazing Pinterest learning projects and experiments with them, I know my limitations in this current situation,” she says. “I recognize I don’t have the bandwidth to put the activities together and execute them. I’d rather use my creativity to break their lessons into something they won’t fight me on. I also recognize that letting them watch Bill Nye the Science Guy for their science lesson is OK. We don’t have to build papier-maché volcanoes.”

Develop and Maintain Routines

Melissa Lee lives in the San Francisco Bay Area, where California’s governor said on March 17 that all schools would likely remain closed through fall of 2020. While Lee works from home for a remote/distributed company and while her diabetes management is already part of her routine, her 10- and 8-year old have been home since March 16, “and their rather robust independent study coursework that our schools sent home has been our biggest challenge,” she says. “I find that keeping to our routine has been key: mealtimes, food types, snacking behavior and bedtime. The more we can feel like business as usual, the more predictable my diabetes will be.”

Leaning into the familiar is a way to foster normalcy when things are very much not normal now, says Lee. “Accept that there will be some things that can be controlled, like your routine and behaviors, and some things that can’t, like your stress level and how that may impact your glucose levels.” While having family in close quarters may make it harder to spend time on yourself, she says, “consider how you might use this time to nurture some new habits without the pressures of having to be somewhere.”

We’re All in This Together

Know that everyone is doing the same as you—living with the same pandemic situation, working from home, parenting kids—and even if everyone you know doesn’t have diabetes, just about everyone has something they are concerned about, whether that is another health condition, concern for family or friends with health issues, economic worries, and so on. Do what you can to manage stress.

“Stress is the main contributor to fluctuating glucose levels,” said Shannon Brumley in Boston. At work, she directly oversees a staff of two and indirectly oversees a staff of ten. “To manage stress, I ensure my staff and I are comfortable taking breaks—some to tend to children,” she said. Exercise, particularly for those in sedentary jobs, is also important. “Not getting outside, especially when the weather is crummy, will compound stress levels. Today, when the weather was nicer, I took advantage of the day and my kids and I jumped on our trampoline and took our dogs out for a much-needed walk.”

Overall, know you are likely doing your best. “Everyone is in the same boat and employers should be adjusting expectations and ensuring family comes first,” Brumley said. “I am very fortunate to be able to work from home and still be available to my kids during these trying times.”

About Cheryl

Cheryl Alkon is a seasoned writer and the author of the book Balancing Pregnancy With Pre-Existing Diabetes: Healthy Mom, Healthy Baby. The book has been called “Hands down, the best book on type 1 diabetes and pregnancy, covering all the major issues that women with type 1 face. It provides excellent tips and secrets for achieving the best management” by Gary Scheiner, the author of Think Like A Pancreas. Since 2010, the book has helped countless women around the world conceive, grow and deliver healthy babies while also dealing with diabetes.

Cheryl covers diabetes and other health and medical topics for various print and online clients. She lives in Massachusetts with her family and holds an undergraduate degree from Brandeis University and a graduate degree from the Columbia University Graduate School of Journalism.

She has lived with type 1 diabetes for more than four decades, since being diagnosed in 1977 at age seven.

Source: diabetesdaily.com

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This content originally appeared on diaTribe. Republished with permission.By Marcia Kadanoff with Katie Bowles Tips to reduce the pain and hassle of pricking your finger each time you check your blood sugar levels on a meter When I was first diagnosed with type 2 diabetes two years ago, I struggled quite a bit. I had […]
Source: diabetesdaily.com

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Source: diabetesdaily.com

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