CE Course

Learning Objectives

The typical focus on the day-to-day management of diabetes works well for the general management of the disease but sick days, though hopefully infrequent, carry the highest risk of acute hospitalization for people in this population.

Our program today, “Keep 'Em Out of the Hospital: Sick-Day Diabetes Management”, will examine

the impact of sick days as high risk events in the life of persons with type 1 and type 2 diabetes. This course will examine the physiologic and behavioral impacts of illness on diabetes management and acute risk factors such as hypoglycemia, diabetic keto acidosis and renal failure.

Our learning objectives for today are as follows:

1. Identify two safety risk factors specific to patients with diabetes on sick days.

2. Describe two facets of the physiology that increases risk to people with diabetes on sick days.

3. Identify three appropriate medication adjustments to reduce patient risks on sick days.

In order to achieve our learning objectives, our program today will discuss:

Illness risks and prevention for the diabetes population.

The prevention of diabetic keto acidosis and how to properly adjust medications to both reduce the risks of hyperglycemia on illness defense and recovery, as well as avoiding secondary risks those medications may pose on sick days.

We will also look at how illness may directly impact the self-care of someone with diabetes--and how to help patients build effective self care plans for sick days.

Introduction

Why should we focus on sick days for people with diabetes? This is a chronic disease that requires daily management, so one might assume that a focus on sick days is just an extra burden for an event that does not happen with frequency. More to the point, it is difficult getting patient to meet their long term goals, so should clinicians be spending their time on education and interventions for these 'occasional' events?

The answer is yes, and here's why.

While sick days are not the primary focus of diabetes self-management education, they are critical to reducing the burden of diabetes on our society and the healthcare system.

In 2016 there were over 16 million emergency department visits reported with diabetes as any listed diagnosis for adults over 18. Of those 16 million emergency department visits, 224,000 of those were for a hyperglycemic crisis. And an additional 235,000 were for a hypoglycemic crisis.

Emergency department visits are 6x higher for adults with diabetes over 45 than for those who do not have diabetes. And rates of admission are twice as high for patients with diabetes than for those without.

For individuals living with diabetes, making it to long-term clinical goals isn't possible if they don’t survive sick days!

Examples of sick days

Sick days are days where there is a very high risk of Diabetic Keto Acidosis (abbreviated as DKA).

In 2016 there were 203,000 emergency department admissions for DKA, 85.6% of which resulted in hospital admissions. This is a leading cause of death for people under 30 with Type 1 diabetes. The annual overall death rate from DKA is between 2--5% of people with type 1 diabetes.

Sick days can also be high risk days for hypoglycemia. This type of illness may lead to a reduced caloric intake. Gastrointestinal illness may lead to reduced absorption of foods, and there is a risk of vomiting after dosing for meals. And some illnesses themselves lower blood sugars.

Furthermore, uncontrolled blood sugars can suppress immune response, so that people get sicker and stay sick longer.

Behaviorally the fears caused by a single bout of illness complicated by life threatening DKA or hypoglycemia can lead to long-term clinical decompensation, and the resulting traumatic fears and anxieties often take root in these high stress times. The sense of victimization and lack of support dramatically increases risks for Diabetes Burn Out.

Sick Days, the untaught diabetes complication?

“The etiology of the resurgence of DKA and hyperosmolar hyperglycemic syndrome, or HHS, is unknown, but numerous causes are possible. Infections are a precipitating cause of both DKA and HHS (2), with urinary tract infections and pneumonia being specifically associated with HHS (17). Overall, infections requiring hospitalization among adults with diabetes did not increase from 2000 to 2015 (18). The incidence of skin and soft tissue infections, including cellulitis, foot infections, and osteomyelitis, increased among adults with diabetes from 2009 to 2015, but pneumonia rates remained flat over time (18).

This quote from a research study in the March 2020 Diabetes Care really sums up the impact of sick days on DKA and the marked increase (rather than decrease) that we have seen over time. There are many potential causes for increases in DKA (importantly the fact that insulin prices tripled in the same data period leading to insulin rationing and omission) But the presence of infection and lack of effective sick day education is key among them.

But I feel this quote form a recent study on DKA hospitalizations sums up the topic of the importance of infection prevention and response among our patients with diabetes.