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Key concepts for sick day management – Type 1 Diabetes

Navigating through illnesses with type 1 diabetes requires a nuanced approach that goes beyond the usual considerations. As anyone with diabetes knows, managing blood glucose levels is a delicate balance, and when sickness strikes, the intricacies of this task become even more crucial.

In this article, we delve into key concepts for sick day management tailored to individuals dealing with type 1 diabetes. Whether you’re contending with a common cold, influenza, gastro, or a respiratory infection, having a personalized sick day management plan can make all the difference in maintaining stability and minimizing the risks associated with type 1 diabetes during times of illness.

1. A sick day management plan should be tailored to each participant and commenced when the first signs are noticed (such as a common cold, influenza, gastro or a respiratory infection)

2. Signs and symptoms of significant hyperglycaemia and DKA include nausea, vomiting and/or abdominal pain, increased thirst, polyuria, deep and laboured breathing (Kussmaul breathing), a fruity-smelling breath, feeling drowsy, weak or confused.

3. More frequent blood glucose monitoring is needed during episodes of illness. Every 1-2 hours if BGLs are above 15.0 mmol/L and/or ketones are present; and every 15 minutes if blood glucose levels are 4.0 mmol/L or below and then hourly for 3-4 hours once levels are back above 4.0 mmol/L.

4. Ketone levels should be measured during episodes of illness. For example when blood glucose levels have been above 15.0 mmol/L for 6 hours or more, every 2-4 hours while blood glucose levels remain above 15.0 mmol/L.

5. Blood ketone levels above 1.0 mmol/L indicate the development of ketosis and the need to take appropriate action to prevent DKA.

6. Blood ketone testing is the preferred method of measuring ketosis. Urine ketone monitoring may be used where blood ketone testing is not available.

7. People with type 1 diabetes (and or their carers) should be reminded to never discontinue taking insulin, especially basal insulin. Adjustments to insulin doses may be required, such as taking supplemental doses of rapid acting insulin.  

8. Maintenance of food and fluid intake is important to reduce the risk of dehydration and to prevent hypoglycaemia and the development of ketones.

Clinical Guiding Principles for Sick Day Management of Adults with Type 1 Diabetes or Type 2 Diabetes a Guide for Health Professionals.; 2020.

Case study for a sick day management

A 49-year-old male patient has multiple daily injections (MDI). He is feeling unwell with a cough and sore throat. His BLG was found to be below 4.0 mmol/L. His usual daily doses are:

Rapid/Short-acting insulin
Long-intermediate acting insulin
(Optisulin solostar)

He has Ketones present of more than 1.0 mmol/L on blood test. His blood glucose and ketones were checked 2 hours later and found to be 1.3 mmol/L via blood test. His Total Daily Dose (TDD) would be needed to be determined. Adding up the total would give us a Total daily dose (TDD) of 110U.


5% of TDD = 5.5U

10% of TDD  = 11U

15% of TDD  = 16.5U

20% of TDD  = 22U

What to do?

  • Always keep taking your basal (long-acting) insulin.
  • Continue to eat and drink if possible.
    Try to have 125-250 mls fluid per hour to avoid dehydration.
  • If BGLs remain below 4.0 mmol/L Treat hypoglycaemia with fast-acting carbohydrate (food or fluids or both). 
  • Check BGL every 10 – 15 minutes until above 4.0 mmol/L, then monitor more regularly for the next few hours.
  • Ketones were present (as above) of more than 1.0 mmol/L  on blood test. His blood glucose and ketones were checked 2 hours later and found to be 1.3 mmol/L via blood test.
  • Calculate your Total Daily Dose (TDD) to determine supplemental insulin needs
    Give 5-10% of TDD as rapid-acting insulin every 2 hours. If BGLs are above 8.0 mmol/L, give your usual insulin doses when you eat or drink carbohydrate foods or fluids.
  • A supplemental dose of 5.5U to 11U of rapid-acting insulin would be needed.

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