II. Management: General
- Diabetic action plan based on Blood Glucose Monitoring
- Early contact with medical provider when Glucose control acutely changes (see red flags listed below)
III. Management: Medications
-
Metformin
- Stop when dehydrated (e.g. Vomiting, Diarrhea) and restart when resolves
- Risk of Lactic Acidosis (rare) with Dehydration
-
SGLT2 Inhibitors
- Stop when dehydrated (e.g. Vomiting, Diarrhea) and restart when resolves
- Risk of Ketoacidosis and Acute Kidney Injury with Dehydration
-
Insulin Secretagogues (Sulfonylureas, Repaglinide, Nateglinide)
- Hold for decreased intake and risk of Hypoglycemia
-
Bolus Insulin (e.g. Regular, Lispro)
- Increase Bolus Insulin by 5-20% for consistent Blood Glucose >250 mg/dl
- Hold or decrease Bolus Insulin for inability to take Carbohydrates and risk of Hypoglycemia
- Consider smaller, more frequent Bolus Insulin doses (every 2-4 hours)
-
Basal insulin (e.g. Lantus, Detemir)
- Continue basal dosing despite illness
- Consider decreased basal Insulin Dosing if inability to eat Carbohydrates
-
Insulin Pump
- Make a back-up plan for Insulin Pump failure
IV. Management: Labs
-
Glucose
- Seek medical attention (or call) for Blood Glucose consistently >300 mg/dl on at least 2 consecutive checks
- Watch for Hypoglycemia (esp. with Nausea, Vomiting)
- Consider small servings of juice when unable to eat
- Increase Glucose monitoring while ill
-
Ketones or Beta Hydroxybutyrate (in Type I Diabetes Mellitus)
- Home Ketone monitoring while ill (especially with Blood Glucose >240 mg/dl)
V. Precautions: Red flags warranting repeat examination
- Prolonged Vomiting
- Inability to hold down fluids
- Presistent or Recurrent Hypoglcemia or Hyperglycemia
VI. Prevention: Emergency Supplies
- Extra Insulin
- Glucagon
- Glucometer and test strips
- Ketone testing (urine or blood)
- Fast acting Glucose (e.g. juice, Glucose tablets)
- Syringes and needles (also in case of Insulin Pump failure)
VII. References
- (2023) Presc Lett 30(6): 32-3
- (2012) Presc Lett 20(3): 13-14
- Smith (2018) Am Fam Physician 98(3): 154-62 [PubMed]
- Westerberg (2013) Am Fam Physician 87(5): 337-46 [PubMed]