• You can become seriously dehydrated.
  
• You may even need hospitalization.
  
• You are at risk for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state state (HHS), two life-threatening medical conditions related to these changes in your blood glucose when you are sick.

What You Can Do When You Start to Feel Sick

• The first thing you need to do is drink adequate fluid to prevent dehydration. Aim for 8 ounces every hour.
  
• Increase the number of times you monitor your blood glucose.
  
• Begin ketone monitoring.
  
• Know when to call your doctor

Develop a Sick Day Plan

Be prepared for a sick day: Discuss a plan with your healthcare provider. The following recommendations are taken from the Canadian Diabetes Association and the American Diabetes Association (ADA) guidelines. Your plan should include:

• How often to test your blood glucose. The recommendation is every 3 to 4 hours.
  
• Whether, and how often, to test your urine for ketones. The recommendation is every 3 to 4 hours.
  
• How much fluid to take hourly.
  
• What foods to take. If you have a fever, feel nauseated, or have diarrhea, you need regular caffeine-free soft drinks or sports drinks with sugar or carbohydrates. Small, frequent sips are better than drinking large amounts. Plain, easily digested food such as rice, soup, or frozen fruit bars may help when you are finding it difficult to eat.
  
• Your blood glucose goals for when you are sick. Always take your normal dose of insulin and oral diabetes medications unless otherwise instructed. You and your healthcare provider should agree on blood glucose levels that will prompt you to increase or decrease your medications.
  
• Which antinausea medication or over-the-counter medications you can safely use and when you should take them. People with diabetes should not take some over-the-counter medications.

Guidelines state that you should call your provider when:

• You have been sick for 1 to 2 days without improvement.
  
• You have been vomiting or had diarrhea for more than 6 hours.
  
• Self-testing shows moderate to large amounts of ketones in your urine.
  
• You are taking insulin and your blood glucose levels continue to be higher than 13 mmol/L (240 mg/dL) after taking 2 to 3 supplemental doses of short acting insulin as prearranged with your provider.
  
• You are taking insulin and your blood glucose level is less than 3.5 mmol/L (60 mg/dL) (hypoglycemia).
  
• You have type 2 diabetes, you are taking oral diabetes medications, and your premeal blood glucose levels are 13.5 mmol/L (240 mg/dL) or higher for more than 24 hours.
  
• You have signs of extreme hyperglycemia (very dry mouth or fruity odor to breath), dehydration, or confusion.
  
• You are sleepier than normal.
  
• You have stomach or chest pain or any difficulty breathing.
  
• You have any doubts or questions about what you need to do for your illness.

What Your Healthcare Provider Will Want to Know

You can help yourself and your provider by keeping notes during your sickness.
Your provider will want to know:

• Your blood glucose levels and urine or blood ketone results
  
• What medication doses you have taken and when you took them
  
• Any other medications you have taken, either prescribed or over the counter
  
• How long you have been sick
  
• Your symptoms in the order they began
  
• Your temperature
  
• How well you have done taking fluids and food
  
• If you have lost weight
  
• Any other symptoms
  
• Your pharmacist's phone number

Choose a Partner
Include your family, friends, and coworkers in your sick day planning. It's a good idea to have:

• Someone close by who can remind you of these guidelines when you are feeling blah.
  
• Someone to bring you ginger ale and remind you to test your blood glucose and ketones.
  
• Someone who can pitch in when you are unable to do your daily routine.
  
• Someone who can measure and record blood glucose, test for ketones, administer insulin, take your temperature, and communicate this to a health care professional.

No one likes being sick, but being sick with diabetes can be especially difficult. Having a plan for these difficult days may help you get through them more easily.

References:

• Standards of Medical Care for Patients With Diabetes Mellitus. Diabetes Care [serial online]. American Diabetes Association Position Statement: 2003;26(suppl 1):S33-S50.
• Canadian Diabetes Assoc 2003 Clinical Practice Guidelines for the prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003, 27;2(suppl)