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 Type 1 and Type 2 sick day rules

Key difference:

• Type 1 diabetes has a continuous requirement for insulin
• Type 2 diabetes involves supplementary insulin in an individual who retains insulin secretory capacity.

In type 1 diabetes NEVER stop the insulin altogether (even if running low sugars due to lack of oral intake), but work on the basis of dose reduction.

In type 2 diabetes whilst illness usually requires the same or more insulin, if oral intake is significantly reduced and hypoglycaemia ensues, it is acceptable occasionally to omit insulin.

In all diabetes patients at risk of hyperglycaemia, dehydration can become an important problem alongside illness.  Ensure appropriate fluid intake (3+ litres / day) and generally that there should be some carbohydrate intake (at least 60g carbohydrate/24 hours if possible, although more usual carbohydrate intake of 150-250g is unnecessary) which can be in the form of fluids if necessary (100mls fruit juice =10g carbohydrate)

During illness when oral hypoglycaemic meds are being used it is often appropriate to discontinue these (eg if nauseated or if at risk of dehydration if taking metformin) and consider alternate treatments (eg insulin) if hyperglycaemia ensues.

Specific ‘Sick Day plans’

1  Tablet-Taking type 2 Diabetes

• Don’t stop taking usual therapy
• If on metformin (consider stopping if eGFR <50)
• Ensure adequate fluid intake
• Consider additional insulin therapy
  • Daily Basal (NPH / LAA)  (Body Weight x 0.2 – at night)
  • Twice Daily Mix / NPH  (Body Weight x 0.1 – 08.00 / 20.00)
  • Soluble insulin given when required (Body Weight x 0.1 – 6 hrly)

2  Insulin-Using type 2 diabetes

• As for tablet-using
• Metformin as previously discussed
• Insulin:
  • Daily Basal (NPH/LAA)   -   add 6hrly when required 10% total daily insulin dose (TDD)& add 50% of total to next day’s dose
  • Twice Daily Mix   -  add 10% total daily insulin dose(TDD) to doses ± given when required between doses
  • Basal-Bolus  -  treat as for type 1

3  Type 1 Diabetes

• In type 1 diabetes when insulin increments are being suggested (either as an additional to usual doses or as given when required corrective doses) a single dose addition of 10% of total daily insulin dose (three times daily) is a sensible starting point if previous experience is lacking.
• In type 1 diabetes if ketones are monitored and present (greater than 2+ on urine dip or greater than 2mmol/L on blood testing) additional dose increments should be doubled (ie 20% TDD).

• Insulin requirements continuous

  • More basal (50-100%)

  • Sometimes less CHO-related

  • ‘Always’ more resistant to insulin (therefore hypos when they do happen are dramatic)

• Correction vs planned dosing (think 24hrs ahead)
• Fluid and Electrolyte requirements
• Carbohydrate requirements
• Monitoring

  • Glucose

  • Ketones