If you have type 1 diabetes, you are no more likely to get sick than those without diabetes. However, if you are ill, diabetes management becomes challenging. During sickness, the body produces stress hormones. These hormones help the body fight off the infection or virus. However, they also act against insulin.

If insulin is not working, or if there is too little circulating, glucose builds up in the blood stream and is unavailable to cells as a source of energy. The body makes up for this by burning fat. When fat is burned, toxic ketones are produced. Producing too many ketones, too quickly, is bad news. It upsets the delicate balance of body chemistry and can lead to a state called diabetic ketoacidosis (DKA) – and that is dangerous.

Diabetic ketoacidosis (DKA) can quickly develop if the illness is not managed properly. As the ketone level rises, the blood becomes more acidic. Dehydration combined with the acidic blood causes DKA.

Symptoms of DKA include:

thirst
frequent passing of urine
sore stomach
nausea and vomiting
deep rapid breathing
extreme tiredness that can lead to unconsciousness.

These symptoms are due to lack of insulin. More insulin is needed to allow the body’s cells to use available glucose and stop it from burning fat for energy. When ketones cause vomiting, deciding to stop injecting insulin (thinking you might not need it because you’re not eating) could result in severe sickness or even death.

Another concern with illness is dehydration. If you are nauseated, you may not be drinking enough. Diarrhea, vomiting, and increased passing of urine caused by high blood glucose and ketones can cause fluid loss. Fluid requirements are actually increased and failing to drink enough liquid during illness can dehydrate you. This throws off the balance of electrolytes such as sodium and potassium in your body.

Stomach flu with vomiting and or diarrhea may cause low blood glucose, although this is less common in teens and adults. You may not be able to eat or drink enough food or fluids containing carbohydrate to work with the insulin you injected or you may not be absorbing nutrients as usual.

In summary, when you are sick you must be aware of these possible complications:

high blood glucose and ketones leading to diabetic ketoacidosis (DKA)
dehydration
and low blood glucose (although it is less common).

Knowing how to manage illness and having the right supplies on hand can prevent these potentially life-threatening complications.

Managing diabetes when ill

Five Simple Sick-Day Rules

Check your blood glucose every two to four hours around the clock.
Check urine or blood for ketones.
If ketones are present, contact your health care professional for further guidance.
Always TAKE insulin.
If blood glucose is high with positive ketone levels, take
extra rapid-acting insulin every 2 hours or regular-acting every four hours (even if you cannot eat).
Drink lots of fluids.
If you are vomiting repeatedly or have large amounts of ketones, call your doctor or diabetes educator or go to emergency.

Michelle fumbles for her alarm, hitting the off button. She feels so wretched. All she wants to do is roll over and go back to sleep. Instead, she drags herself out of bed and fetches the illness management kit she and her mom prepared before she left for university. She follows the simple, step-by-step instructions located inside the box (see Sick-Day Rules sidebar).

When you are sick, you must know your blood glucose level. Check it every two to four hours around the clock. If you want to sleep, set an alarm so that you will wake frequently to test. If your blood glucose is above 14 mmol/L, it is recommended that you check your blood or urine for ketones.

A few products are available. Your doctor or diabetes educator may recommend one over the other. (The Precision Xtra™ meter can be used to check your blood. Two urine testing products are also available – Chemstrip™ uGK or Ketostix™. Be sure to read the package insert regarding shelf life and storage. Mark the date of opening on the bottle and throw the strips away once they have expired. Outdated strips can give a false negative reading.)

Michelle checks her blood glucose. It is 18 mmol/L. She makes her way down the hall to the washroom and checks her urine for ketones. The strip indicates that her ketones are trace. On the way back to her room she is hit by a wave of nausea and rushes back to the washroom to vomit. She decides to call her diabetes educator.

The most important thing to remember when you are sick is always take insulin, even if you are unable to eat or you are vomiting. High blood glucose and ketones mean you need extra regular or rapid-acting insulin. Usually, you would need extra insulin totalling around 10 to 20 per cent of your total daily dose. Give extra rapid-acting insulin every two hours (or regular-acting every 4 hours) until your blood glucose is below 14 mmol/L or your ketones are negative. Ensure that you have a detailed sick day management plan worked out with your doctor or diabetes educator well in advance so that you are not guessing during a time when you are also feeling sick.

Rarely, you might need to reduce your insulin when you are sick. If your blood glucose is below 7 mmol/L and you are unable to eat, lower your insulin by 20 per cent. Remember: never stop taking insulin!

Make sure you are drinking enough to prevent dehydration. Try to have one cup of fluid per hour. If you are nauseated, sip fluids. If your blood glucose is above 14 mmol/L, choose sugar-free liquids. If below 14 mmol/L, select fluids containing sugar. If you are vomiting and/or have diarrhea, try chicken broth and sports drinks such as Gatorade™ to prevent electrolytes in your blood from dropping too low.

Finally, know when to get help. Call your doctor or diabetes educator if you have any concerns or are unsure of how to manage your diabetes. Do not guess. If you do not have a detailed sick day plan with information about insulin dosing in the presence of high blood glucose or when ketones are present, it is better to be safe than sorry. A good rule of thumb is to go to emergency if you are unable to keep fluids down, have vomited more than two times in four hours, have blood ketones above 3.0 mmol/L, or are showing moderate to large levels through a urine test. You may have life-threatening DKA, or at the very least a stomach flu that will cause dehydration. You need medical help!

Have supplies on hand

Plan for unexpected illness. When you are home alone and sick, you must have illness management supplies on hand. You may be too ill to make a trip to the pharmacy or corner store. Keep the following items in an ‘illness management kit’ (shoe box or plastic container) so that they are ready when you need them.

instructions on managing illness (see Five Simple Sick-Day Rules sidebar)
a new bottle of ketone strips
an extra bottle of blood glucose strips
a loud alarm clock
regular and diet pop, Gatorade™, chicken soup and crackers
cab fare, in case you must go to emergency and are too sick to walk or drive
a list of phone numbers for:
your diabetes educator and doctor
- a friend or family member who can help you
- a local health information line
- a taxi company.

Michelle’s diabetes educator decides that Michelle doesn’t need to go to the emergency room yet but keeps in touch every two to four hours. Although she will not be eating anything, Michelle follows her sick day plan and takes her usual dose of insulin plus an extra 10 units of rapid-acting insulin (20 per cent of her total daily dose of insulin). She has a few sips of diet ginger ale and sets her alarm so that she will wake again in two hours.

Michelle continues to check her blood glucose and ketone levels every two hours. She gives herself another injection of rapid-acting insulin two hours later. Although she is nauseated, she drinks diet pop and Gatorade™. By mid-afternoon she feels a bit better.

Her blood glucose is down to 12 mmol/L and her ketones are negative. She heats up some chicken noodle soup and nibbles on some crackers. Thanks to her sick day knowledge and illness management supplies, Michelle will get well soon!

Home Alone and Sick Managing Type 1 Diabetes and illness on your own

Extra challenges of illness

Managing diabetes when ill

Five Simple Sick-Day Rules

Have supplies on hand

Michelle continues to check her blood glucose and ketone levels every two hours. She gives herself another injection of rapid-acting insulin two hours later. Although she is nauseated, she drinks diet pop and Gatorade™. By mid-afternoon she feels a bit better.

Her blood glucose is down to 12 mmol/L and her ketones are negative. She heats up some chicken noodle soup and nibbles on some crackers. Thanks to her sick day knowledge and illness management supplies, Michelle will get well soon!

Home Alone and Sick
Managing Type 1 Diabetes and illness on your own