When you are unwell
sick day action plan
Diabetic ketoacidosis

When you are unwell – Type 1 diabetes

A minor illness can result in a major rise in blood glucose levels. This will increase the amount of insulin you need to keep blood glucose levels within the target range. If the blood glucose levels remain high for several hours the body will start to produce ketones.

Ketones are toxic, and if they build up to moderate to high levels, a life threatening condition called diabetic ketoacidosis (DKA) can develop (see symptoms of DKA below). Careful monitoring of blood glucose and ketone levels and adjusting your insulin accordingly should help to keep you out of hospital.

At the earliest sign of any illness such as a cold or virus, it is important for you to take action. Start following a Sick Day Action Plan immediately if:

  • You are unwell or have any signs of illness even if your blood glucose levels are normal
  • Your blood glucose levels are greater than 15mmol/L for 6 hours or more, even if you are feeling OK
  • There are ketones in your urine or blood

You may have reasons for implementing the action plan earlier, such as how your body reacts to infections or how tightly controlled your blood glucose levels are. You should discuss this with your diabetes team.

Sick Day Action Plan – What to do – Six Steps

1.   Managing your blood glucose levels when you are feeling unwell can be difficult especially if this is the first time. Phone your doctor or diabetes team early so that they can help you manage the situation and assess the underlying illness. If you are not feeling well enough to be constantly testing your blood glucose levels, try to organise someone to stay with you to provide support.

2.   Check your blood glucose levels more frequently – this is the only way to monitor the effect of illness on diabetes. If your blood glucose levels are above 15mmol/L (for more than six hours or earlier if advised by your diabetes team) you should check blood glucose levels and ketone levels two hourly. Ketone levels can be tested with either urine testing strips or blood testing strips (using an Optium or Xceed meter).

3.   Keep drinking and eat if possible. Try to have one cup of fluid (125 – 250 mls) every hour to avoid dehydration. If you can try to eat that will help maintain energy requirements and prevent low blood glucose levels. If you are too unwell to eat, and/or your blood glucose level is less than 15mmol/L you should drink sweetened fluids (e.g. ordinary soft drink or tea/coffee with 1 tablespoon of sugar or honey) or if your blood glucose level is more than 15mmol/L drink sugar free fluids (e.g. water, diet drinks or tea/coffee with no added sugar).

4.    Continue taking your usual insulin doses. Even if you are eating little or are vomiting and have diarrhoea, you should continue your regular insulin regimen. Supplement doses of insulin are:

  • In addition to the usual insulin dose
  • Given straight away and not delayed until the next regular insulin dose is due
  • Calculated as a percentage of the usual total daily dose i.e. per centage of total of short and long acting insulin for the day (see sick day action plan for a guide to extra insulin on sick days)

Occasionally blood glucose levels can fall during illness, so you may need to reduce your insulin dose.

5.   Get yourself to hospital or medical clinic if

  • Vomiting is persistent, especially if frequent for more than two to four hours
  • Your blood glucose continues to rise despite two extra insulin doses or you are not able to give yourself extra short/rapid acting insulin
  • Your urine ketones are moderate to high or blood ketones are more than 1.5mmol/L and do not decrease with extra insulin dose
  • You are feeling drowsy, confused, having difficulty breathing or have abdominal pain
  • Hypoglycaemia (low blood glucose level) is severe and BGL cannot be kept above 4mmol/L
  • You are too unwell and you or your support people are unable to carry out the monitoring required.

Women with type 1 diabetes who are pregnant may need to be more cautious and seek medical advice with any signs of illness.

6.    Be prepared for the next time when you are unwell – have a Sick Day Management Kit. This should be discussed with your diabetes team and every six months, check that your kit is fully stocked with items that are within their expiry date.

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Suggested items for your sick day management kit

  • Print a copy of the Sick Day Action Plan to discuss with your doctor and follow when you are unwell
  • Short acting or rapid acting insulin
  • Insulin syringes or insulin pen
  • Food for sick days and drinks (including sweetened and diet drinks)
  • Glucose containing food or gel and glucagon (if recommended by your diabetes team)
  • Pain relief such as paracetamol or ibuprofen
  • In date test strips for glucose and ketone testing

Diabetic ketoacidosis (DKA)

DKA is a potentially life threatening condition that can occur in people with type 1 diabetes, and rarely in people with type 2 diabetes.

When there is insufficient insulin to meet the body's needs, the body starts to breakdown fat for energy. Ketones are the by-product of fat breakdown which are toxic to the body in large amounts.  If they accumulate in the blood they can cause ketoacidosis. Diabetic Ketoacidosis (DKA) is a very serious condition so urgent medical attention in hospital and treatment with insulin and fluids is required.

DKA can occur in people with type 1 diabetes when:

  • It is not diagnosed correctly and insulin treatment is delayed
  • You miss your insulin dose or don't take enough insulin
  • During illness, blood glucose levels usually rise and extra insulin is needed
  • Insulin pump or pen failure and the full dose of insulin is not given

Symptoms of DKA

  • Excessive thirst and urination, tiredness (high blood glucose)
  • Muscle cramps
  • Flushed facial appearance
  • Nausea and vomiting
  • Abdominal pain
  • Dehydration
  • Acidotic breath (sweet smelling)
  • Difficulty breathing
  • Drowsiness, coma

People with diabetes experiencing these symptoms should go to hospital for emergency assessment and treatment.

Fortunately, DKA can be prevented in most cases as long you know what to do with your insulin, when to seek help when unwell and follow your sick day action plan.

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