Sick day rules for multiple daily injections

Sickness is an unavoidable part of everyday life. The body’s natural response to illness results in higher blood glucose levels due to the release of stress hormones. During illness, you will need frequent blood glucose monitoring and often more insulin than usual.

What are ketones?

Ketones are acids which can make you feel very sick. They are produced when body is not getting enough food (glucose) or your body is not able to use glucose due to lack of insulin. If you do not get rid of ketones, you can become dehydrated and eventually develop diabetic ketoacidosis (DKA).

Check for ketones whenever you are ill, regardless of your glucose levels as you can have raised ketones with normal glucose levels such as starvation ketones with gastroenteritis.

Sick day rules

Never stop the insulin. Even if you are eating less than normal, your body needs insulin to use glucose and to get rid of ketones.

Check your blood glucoses more frequently for example, every 2 hours including throughout the night.

Check for blood ketones. Give additional fast acting insulin every 2 hours if blood glucose is above target.

If ketones are present when blood glucose is low, they are called ‘starvation ketones and respond to drinking extra fluids containing sugar. This can happen when you are being sick lots or have diarrhoea. Monitor blood glucose very closely, and extra insulin may be needed when blood glucose starts rising. Treat hypoglycaemia (blood glucose less than 4.0 mmol/L) as you usually do. Contact the hospital for advice if struggling to keep blood glucose over 5 mmol/L.

Keep well hydrated by drinking plenty of fluids. Water or sugar-free fluids are probably most appropriate in the majority of cases where blood glucose levels are normal or high. If blood glucose levels are low, sugary drinks are needed or eat carbohydrates if possible. Avoid carbonated drinks if possible.

Inform the diabetes team early to seek advice.

You should contact the hospital if:

• you are not confident in managing high ketone levels
• your child is being sick
• ketones are over 1.5 mmol/L, regardless of blood sugar levels, for 6 hours or more when following the sick day rules advice

• If ketones are less than 0.6 and blood glucose is 8 mmol/l or more, follow this first column of advice again.
• If blood glucose is 8.1 mmol/l or more, and ketones are between 0.6 and 1.4, follow the second column of advice.
• If blood glucose is 8.1 mmol/l or more, and ketones are 1.5 or more, follow last column advice.

If ketones are more than 1.5mmol/L for more than 6 hours or if your child is being sick with high ketones or having difficulty breathing, bring them to A&E.

Calculating total daily insulin

Total daily insulin (total daily dose) is all the insulin you usually have in a day. This will vary a bit depending on what you eat each day. Follow the points below to work out you total daily insulin:

1. What is the total basal (background) insulin?
2. How much insulin do you usually short-acting with breakfast?
3. How much insulin do you usually short-acting with lunch?
4. How much insulin do you usually short-acting with tea?
5. How much insulin do you usually short-acting with supper?
6. Do you usually have any snacks needing insulin? If yes, write the amount of insulin for each snack down:

You now need to add all the amounts of insulin above up to get your total daily insulin (total daily dose).

To work out 10 percent of your total daily dose, take the total daily insulin, and divide it by 10.

To work out 20 percent of your total daily dose, take the total daily insulin, and divide it by 10, and then times that by 2.

For example:

Please download this diabetes sick day rules chart for multiple daily injections to keep at home.