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Sick-Day Insulin Plans First let’s look at insulin.
The good news is that most illnesses raise blood sugar, so we will be increasing basal to meet the blood sugar needs with a goal of holding blood sugars steady between meals or overnight. Illnesses that don’t cause ketones typically will need a basal increase of 25-50% for a 24-hour period. However, illnesses that do cause ketones often require 50% or more (often far more) basal increases. This is simple with a pump via temporary rate adjustments. But if you’re on long-acting injected insulin this can be tricky. For instance, what if I need 80% more today, but not tomorrow? It can feel really risky. One good option to reduce the risk would be talking with your prescriber about having NPH insulin on hand for sick-days. This is a roughly 10-hour acting form of insulin that can be used for these times. It’s got a bit of an action curve, but it is also a shorter action time than a full 14-hour commitment.
But what if we have ketones without a BG increase? We still want to increase basal insulin! This forces the body into carbohydrate metabolism and reduce ketone production. A 30-50% basal increase should see ketones levels reduce. In this case the PWD will need to intake more carbs to offset the added insulin. Sucking on a hard candy, popsicles, jello or a watered down sports drink are great options here.
There is an important consideration to be made here. If insulin is getting into the body properly, hydration is going well and the insulin has been increased, but ketone levels are increasing instead of decreasing, it's important for your patient to seek medical attention immediately. This could indicate that they are dealing with a more severe infection of other issue requiring assistance. Now let's talk about the rock and the hard place. Take a look below to see the problem.
To explain this, think about what happens if you have ketones, and so need more insulin. Then compound that with an inability to keep[ food down. If a person with diabetes can’t keep down any form of carbohydrate they are in a dangerous spot, their “diabetes brain” tells them to reduce insulin to avoid a low. Makes sense, right? No--STOP before falling victim to this situation!!! Remember your golden rules!!! If you're sick it means there is a pathogen somewhere causing an infection, which means you are at high risk for DKA! So CHECK FOR KETONES! If they are present and increasing you will need to get more insulin in! Without the additional insulin you could end up in the ICU, DKA or hypoglycemia. Even patients not using insulin may see hypoglycemia risks rise. SGLT2 medications may continue to increase glucose release in the urine, even if blood sugars are lower and intake levels are reduced. Sulfonylureas may need to be reduced or held entirely when intake levels drop or your patient is at risk for nausea/vomiting. GLP1 or metformin may exacerbate GI symptoms and increase risks of vomiting or diarrhea which, in turn, raise hypoglycemia risks. So, we now have a patient with insulin or medication in their system, possible ketones due to illness, but they can not intake enough carbs to keep their blood sugars from dropping. We are caught between an ambulance for severe hypoglycemia, or an ambulance for DKA! But there is a way out--Glucagon to the rescue!
A great option here is to microdose glucagon. A full dose of glucagon (0.5 ml for kids 1 ml for adults) will cause the liver to dump a lot of stored glucose and push blood sugars very highfast, but a minimdose (10 units for kids, 20 units for adults) taken with a regular insulin syringe will push blood sugars up enough to keep insulin going, and even increase it to offset ketone production. Glucagon can be injected into a muscle for fast action to head off an imminent low, but can also be injected it subQ to absorb slowly to match the basal insulin needs that have increased. We can continue to use our injectable glucagon for up to 24 hours as long as it is kept cold and does not start to clump, gel or get cloudy in the vial. (It should be as watery and clear as rapid acting insulin) Note that it is not possible to mini-dose Baqsimi or the Gvoke hypopen. For this reason I recommend that prescribers write one Rx for rescue glucagon “for Tx of severe hypoglycemia” and a glucagon prefilled syringe or kit for the “prevention of DKA per sick-day protocols”. That way insurance will cover the same medication in two different formulations because it is for different, distinct issues. |
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