Diabetes Forecast

Keys to Sick-Day Management

How to prep for and deal with illness when you have diabetes

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You’re pretty good about managing your diabetes. You check your blood glucose regularly, take your meds as prescribed, and keep glucose tablets on hand in case of unexpected lows. But then, despite your best efforts to stay healthy, you’re hit with a cold, a stomach bug, or even the new coronavirus (COVID-19). Are you prepared to manage your diabetes while you’re on the mend?

People with diabetes aren’t more likely than others to be infected with a cold, the flu, a stomach bug, or COVID-19, but when they are, they’re more likely to become seriously ill. For instance, a study of Chinese adults, published in March in Diabetes Metabolism Research and Reviews, found that those with diabetes were more likely to have serious health issues from COVID-19, including severe pneumonia. And in a study published in March in Morbidity and Mortality Weekly Report, researchers studying COVID-19 data found that U.S. adults with diabetes and other underlying conditions, such as heart disease, were more likely to be hospitalized and admitted to the intensive care unit.

Even the annual flu can raise your chances of pneumonia and hospitalization. “The flu can be devastating, even without the background of diabetes,” says endocrinologist Elizabeth Halprin, MD, clinical director of the adult diabetes section at the Joslin Diabetes Center in Boston. It can take up to three weeks to fully recover from even the mild symptoms of fever, cough, sore throat, muscle aches, and fatigue.

Sick day planning is important, now more than ever. By preparing while you’re well, you can take the extra steps necessary to stay on top of your diabetes management at the first sign of sickness.

Plan Ahead

Keeping your blood glucose within your target range will help you better deal with future illness. “People with impaired immune systems need to be more prepared,” says Marwan Hamaty, MD, an endocrinologist with the Cleveland Clinic. “Having controlled blood glucose to start with will help fight the infection.”

From there, take these additional steps to ready yourself for potential sickness.

Create a Sick-Day Plan

Your diabetes treatment may need to be tweaked if you get sick. Now is the time to learn how.

Ask your doctor about frequency of blood glucose checks, timing of ketone tests, and what to do if your illness worsens. For instance, vomiting or diarrhea for several hours, blood glucose consistently above 250 mg/dl, dizziness or exhaustion, and a fever above 101 degrees for longer than 24 hours are all reasons to contact your health care provider. Your doctor may also recommend changes to your diabetes medications during times of sickness. Get all of these details in writing so you can refer back to them if you come down with something.

With your dietitian, plan a variety of simple sick-day foods (think: chicken soup and Jell-O) and make sure you have the ingredients on hand.

You’ll also want a list of your doctors, in-case-of-emergency contacts, medications, insurance information, and health conditions printed out on a piece of paper. “You want multiple copies available,” says Marlisa Brown, MS, RDN, CDCES, CDN, spokesperson for the Association of Diabetes Care & Education Specialists. “It could be on your refrigerator, in your wallet, so any emergency worker will be able to get all the information they need to treat you.”

Make a Sick-Day Kit

Grab a container and add the essentials: a spare glucose meter, extra batteries, backup supplies for your insulin pump or continuous glucose monitor (CGM), ketone test strips, and enough blood glucose–lowering medication to last a week. But keep in mind that injectable meds shouldn’t be stored for longer than 30 days before use.

You’ll also need glucose tablets or gels in case of hypoglycemia (low blood glucose). While you’re at it, check your glucagon kit to make sure it hasn’t expired.

Don’t forget to store items for treating a cold or the flu. Over-the-counter drugs are fine, but talk with your doctor or pharmacist about choosing medications that won’t interfere with your diabetes management. They’ll probably recommend sugar-free cough syrup. “Over-the-counter medications, especially the older formulations of cough syrup, which has a lot of sugar, can increase blood glucose significantly,” Hamaty says.

Your health care provider may also suggest alternatives to decongestants that contain pseudoephedrine, which can raise blood pressure and blood glucose. Some options include nasal sprays, which are safer for the heart, or oral antihistamines such as Benadryl or Zyrtec. 

Get Your Ducks (and Other Small Creatures) in a Row

You may need to make arrangements with family or a neighbor to walk your dog or help out with your kids’ activities. Having someone on standby can also help if any last-minute errands come up, such as an emergency medication refill. Figure out the plan before you get sick so you’ll know who to call when you’re in a pinch.

Treat Yourself

We generally think of respiratory diseases like influenza as striking during the winter, with peak season occurring between October and December. Even the word “influenza” likely comes from the Italian phrase influenza di freddo, or “the influence of the cold.” But you catch the flu from a virus, not icy temperatures, and while that virus seems to thrive better in cold, dry environments, individual cases spring up year-round. In fact, a study published in 2017 in PLOS Computational Biology found that new flu pandemics are likely to emerge in spring or early summer. (It’s still too early to say how COVID-19 will behave during seasonal changes.)

No matter when you get sick, these steps will help you get past it.

Check, Check, and Recheck

Even if your blood glucose is ordinarily in your target range, sickness is guaranteed to drive it higher than normal. “Elevated glucose levels might be the first sign of an illness and in that way might act as a barometer of something brewing that might otherwise not be detected until later,” Halprin says. That’s because your body releases hormones to fight the illness that have the unfortunate side effect of elevating glucose.

While high blood glucose is always a problem for people with diabetes, its effects are generally seen over a long period of time. But when you’re sick, sustained highs can quickly take your illness from bad to worse.

That’s why it’s important to monitor your levels more closely than usual. In addition to your normal checks (such as upon waking and before meals), do a finger stick every four hours if your numbers are in range. (No need for middle-of-the-night checks if all’s well during the day.) If your meter reveals a high number, check again in an hour. If your level is lower than normal, check again in 15 minutes to be sure you’re not slipping toward hypoglycemia.

Mind Your Meds

Depending on your specific regimen, your doctor may ask you to adjust your medications while you’re sick. Many type 2 diabetes meds have side effects that can increase your risk for severe illness if you’re fighting the flu. They may cause worsening dehydration and increase gastrointestinal symptoms. “For that reason, it’s often necessary for someone with type 2 to use insulin when they are very sick with the flu or other illness,” says Halprin.

If you take insulin, your doctor will likely stress the importance of both long-acting (basal) and rapid-acting (bolus) doses, even if you’re not eating as much. “Illness is one of the things that makes people with diabetes more insulin resistant, meaning they will need more insulin to do the same job,” Halprin says. “Glucose levels will be elevated, even without eating, and if you don’t take insulin, your glucose levels will climb even more.”

Test for Ketones, Too

When your body doesn’t have enough insulin to usher glucose into your cells, it gets energy by burning fat instead. This process produces ketones, too many of which can make blood acidic. The result: diabetic ketoacidosis (DKA), a serious condition that can lead to coma or death.

The hormones your body releases to fight illness (often called “stress hormones”) not only elevate glucose, but also make insulin less effective. The result: Ketones develop. Dehydration due to vomiting, diarrhea, and a lack of fluid intake can also cause ketone levels to rise rapidly. That’s why it’s so important to stay hydrated and continue to take insulin regularly (even without eating) during a serious illness.

Have test strips on hand to check for urine ketones. If you have type 1 diabetes (or have type 2 and are on basal-bolus insulin therapy), talk to your doctor about how often to check for ketones. The ADA recommends checking every four to six hours when you’re sick or when your glucose is above 240 mg/dl. And check immediately if you exhibit any of the warning signs of DKA:

  • High blood glucose
  • High ketones
  • Thirst or dry mouth
  • Frequent urination
  • Drowsiness
  • Dry or flushed skin
  • Nausea, vomiting, or abdominal pain
  • Difficulty breathing
  • Fruity odor on breath
  • Confusion

If your glucose is trending high but you test negative for ketones, correct the high with a dose of insulin and continue to monitor. If you test positive for moderate or high ketone levels, continue to correct your high glucose levels with insulin and contact your health care provider immediately.

Stay Hydrated

Drinking plenty of liquids is one of the most important steps for avoiding hospitalization from sickness. Dehydration will increase your blood glucose and, as Brown points out, “if you have high blood glucose, you’re already losing fluids because the body is trying to get rid of the sugars through urination.”

Drink at least 6 to 8 ounces of non-sugary fluids per hour. If you’re having trouble keeping liquids down, take a few sips every 15 minutes.

Don't Forget Your Flu Shot

Get your annual flu shot. The American Diabetes Association’s 2020 Standards of Medical Care in Diabetes recommends influenza vaccines for everyone over the age of 6 months. If you have diabetes, this significantly reduces your likelihood of being hospitalized.



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