Being sick with diabetes: what changes, and what does not

It is a Sunday, and you have been up since four with a stomach bug. You have not kept anything down since last night.

The pills are on the counter where they always are, and you are standing there working out, on no sleep and no food, whether taking them today is the right thing or the wrong thing.

That is the worst possible moment to be figuring this out, which is the whole point of this article.

Being ill pushes your numbers up, even when you are not eating

Most people expect the opposite, so it is worth saying plainly.

When your body fights an infection it releases stress hormones, and those hormones raise blood sugar. They also make insulin work less well than usual. So a bad cold or a chest infection can push your readings up for days, even if you have barely eaten.

That surprises people, and the surprise is where trouble starts. “I have not eaten, so I do not need my medication today” is a reasonable-sounding thought that leads somewhere bad, particularly for anyone who takes insulin.

Vomiting and diarrhea add the other half: you lose fluid faster than you can take it in, and dehydration changes how your kidneys handle several common medications.

The conversation to have while you are well

Ask your care team for a sick day plan, this week, on a day when nothing is wrong. Diabetes Canada recommends having one worked out in advance, and a good one is short enough to stick on the fridge. It should answer, for you specifically:

• How often to check your blood sugar while you are ill
• Whether to check ketones, with what, and at what point
• What to do about food and fluids when you cannot face eating
• Which of your medications to keep taking, and which to pause, and for how long
• Who to call, and at what point in the day rather than “if it gets worse”

That fourth item is the one that cannot be answered by an article, and we are not going to try.

The plan you want is the one you made before you needed it.

The medications that need that conversation specifically

Naming them is useful, as long as it is clear what the naming is for. This is a list of what to ask about, not a list of what to stop. Nothing here is an instruction to change anything.

Several medications are commonly paused during an illness with vomiting, diarrhea or a high fever, because dehydration changes how the kidneys handle them. The usual ones are metformin; the SGLT2 inhibitors, which include empagliflozin, dapagliflozin and canagliflozin; ACE inhibitors such as ramipril and perindopril; ARBs such as candesartan and telmisartan; diuretics such as hydrochlorothiazide and furosemide; and anti-inflammatory painkillers such as ibuprofen and naproxen. Your prescriber or pharmacist decides which of those applies to you, and writes it into your plan.

Insulin is different, and this is the part most often got wrong. Insulin is usually not something to stop when you are ill, even if you are eating very little, and stopping it can be dangerous. What your plan may change is the detail, and the detail belongs to your prescriber. If you are unwell and unsure about insulin, that is a call to make today, not a decision to make alone at the kitchen counter.

One more, because it is specific and it catches people out. If you take an SGLT2 inhibitor, it is possible to develop a serious condition called diabetic ketoacidosis with a blood sugar that looks close to normal. So nausea, vomiting, stomach pain, deep or fast breathing, or a fruity smell on your breath need urgent assessment even if your meter looks reassuring. Ask your team whether ketone testing should be part of your sick day plan.

Fluids, and food when you cannot face food

Sip small amounts often rather than drinking a lot at once. Small and frequent stays down when a full glass will not.

If you cannot eat, some plans switch to fluids that carry some carbohydrate, particularly for people taking insulin or a sulfonylurea such as gliclazide, glyburide or glimepiride, because those medications keep lowering blood sugar whether or not there is food. Which fluids, and how much, is part of the plan your team writes with you rather than something to improvise.

Check more often than usual while you are ill, and write down what you find with the time beside it. When you call, a short list of readings and times gets you a far better answer than “high all day”.

Your weight and your blood pressure will also look strange

Two smaller things, so they do not worry you at the wrong moment.

If you weigh yourself, expect the number to drop during a bug and come back afterwards. Losing several pounds over two days is fluid, not fat. That is a normal part of being ill, not progress and not a setback.

Blood pressure often runs lower than usual when you are dehydrated, which is one reason people feel dizzy standing up during a stomach bug. If that is happening, stand up slowly, and mention it when you call.

When to call, and when not to wait

Call your care team the same day if you cannot keep fluids down for more than a few hours, if vomiting or diarrhea has gone past a day, if your blood sugar stays higher than your usual range for more than a day or two, if you have had any low you needed help to treat, or if you are simply unsure whether to take something. That last one is a good reason to call, not a small one.

Call 911, or go to an emergency department, for chest pain or pressure, trouble breathing, deep or rapid breathing, confusion or unusual drowsiness, a fruity smell on the breath, a seizure, or someone becoming difficult to wake. Do not measure first.

Nobody at a clinic thinks you are overreacting by calling about a stomach bug. Sick days are one of the things a care team is genuinely for.

One small place to start

You are probably reading this while perfectly well, which makes today the right day.

Ask your care team for your sick day plan in writing. If you are a 360Care member, message us in the app and we will put it together with you, including which of your own medications need to pause and what to do about your insulin if you take it. Stick it on the fridge and forget about it until the Sunday you need it.