General practice management of type 2 diabetes


Sick day management
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Recommendations

Reference

Grade*

Patients should be educated to develop a sick day management plan after initial diagnosis. This plan should be reviewed at regular intervals

261
Australian Diabetes
Educators Association, 2014

None provided

Assist in the development of a sick day care plan and preparation of a home sick day management kit for patients to use during episodes of sickness

261
Australian Diabetes
Educators Association, 2014

None provided

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence  


Clinical context


Patients with diabetes require careful individualised management during times of illness (due to other causes) to prevent:

  • hyperglycaemic and hypoglycaemic emergencies
  • hyperosmolar hyperglycemic state
  • DKA – uncommon (plus consider normoglycaemic DKA with SGLT2i medication).

A clear and specific action plan ensures that patients can either self-manage or have access to their healthcare team for advice and early intervention, supervision and support. General practices and GPs should consider routinely incorporating these plans as part of a patient’s documented management plan.

The ADEA has developed clinical guiding principles for health professionals and a consumer resource on sick day management.261,262 
Patient information is also available from state and territory diabetes organisations.

 

In practice


Sick day management should be tailored to the individual patient and incorporate the following actions:

  • Identify the underlying cause and treat as appropriate. Underlying causes include:
    • intercurrent illnesses, infections (eg skin, urinary tract and chest infections), trauma, acute MI and stroke
    • use of medications such as corticosteroids.
  • An increase in SMBG may be required according to individual circumstances such as those patients at risk of hypoglycaemia or using insulins.
  • Ensure continuity of advice and accessibility – provide telephone access or afterhours support.
  • Review medications – Refer to Table 15.
  • A written action plan (refer to Table 15), which should be regularly updated (at least once annually during the annual cycle of care) and provided to patient and carer.


Table 15. Action plan 

Commence action plan

ReferenceGrade*

Commence action plan

  • When feeling unwell
  • Blood glucose >15 mmol/L on two consecutive readings

Frequent monitoring  of blood glucose

Two to four hourly monitoring, or more frequently if blood glucose is low

Medication

Insulin or diabetes medications should be continued but with assessment on the use of metformin, sodium glucose co-transporter 2 (SGLT2) inhibitors (dapagliflozin, canagliflozin and empagliflozin) and glucagon-like peptide-1 receptor agonist (GLP-1 RA), which may require cessation if vomiting or dehydration is a concern. Increased risks of hypoglycaemia may occur if appropriate intake of meals are not able to be maintained.

Food and water intake

  • Patients should try to maintain their normal meal plans if possible
  • Fluid intake (eg water) should be increased to prevent dehydration
  • Advise about alternative easy-to-digest foods like soups if the patient cannot tolerate a normal diet (some non-diet soft drinks may provide essential carbohydrate in this situation)
  • If blood glucose >15 mmol/L use non-glucose containing fluids
  • If blood glucose <15 mmol/L use oral rehydration solutions (may contain glucose) if needed
  • If unable to tolerate oral fluids and blood glucose continues to drop – inform patient to attend medical care

Seek assistance

Individuals and support people need to assess whether they are well enough or able to follow the guidelines

If not, they should call for help or attend hospital

Practice points from ADEA – Clinical guiding principles for sick day management of adults with type 1 and type 2 diabetes – Technical document261

Special considerations

Different patient groups will need individualising of the sick day action plan

Managed with diet alone:

  • Worsening control may require the introduction of medication and symptomatic management of hyperglycaemia.
  • Patients with type 2 diabetes may have impaired body immune mechanisms that will make recovery slower.
  • In addition, patients may become dehydrated because of the osmotic diuresis.

Managed with oral or non-insulin glucose lowering medication:

  • Worsening control may require the urgent review by the GP or referral to a specialist diabetes service or endocrinologist.
  • Consideration of the use of insulin may be temporarily required for persistent and resistant symptomatic hyperglycaemia (this may require hospital admission).
  • In patients with nausea, vomiting and/or diarrhoea, consider stopping metformin and GLP-1 mimetics temporarily as metformin may aggravate these symptoms and GLP-1 mimetics may aggravate nausea/vomiting, and there may be a risk of acute renal impairment due to dehydration. Cessation of any SGLT2 inhibitor should be reviewed if gastrointestinal illnesses are present as they may further aggravate dehydration and hypovolaemia.

Type 2 diabetes managed on insulin:

  • All patients should be advised to seek the urgent review by their GP or health professional when unwell or the blood glucose is consistently >15 mmol/L on two consecutive SMBG readings as per the action plan. Blood glucose monitoring should be increased to every two to four hours if unwell. Depending on these levels, patients may need to increase their morning intermediate or long-acting insulin dose by 10–20% if the glucose reading remains elevated and, depending on further blood glucose levels, modify subsequent doses of short-acting insulin during the day. Advice on the additional use of oral agents and GLP-1 RA is listed above. Additional blood ketone testing may be incorporated if there are symptoms suggestive of ketosis (eg nausea, vomiting, shortness of breath or fruity odour, abdominal pains, altered consciousness) or there is a past history of DKA, or if the patient is using an SGLT2 inhibitor agent. This must be a documented strategy on their sick day management plan. Note: many patients are only on basal insulin or a premixed insulin. These patients require appropriate medical advice and access to additional rapid-acting insulin to use as a supplemental insulin dose.262
  • Patients with gastrointestinal upset who are not eating, but who feel well and continue their usual activities, may need to reduce their insulin based upon their SMBG readings (especially rapid-acting insulin) to avoid hypoglycaemia.
  • A warning for the use of SGLT2 inhibitors: there have been rare reports of euglycaemic DKA with all the SGLT2 inhibitors – symptoms of possible DKA need to be incorporated in clinical management when considering use of these agents. These agents are not indicated in type 1 diabetes.

     


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  1. Robins M, Coles M, Smith D, Armstrong M, Bryant W, Homeming L, on behalf of the Australian Diabetes Educators Association. Clinical guiding principles for sick day management of adults with type 1 and type 2 diabetes. Technical document. Canberra: ADEA, 2014.
  2. Australian Diabetes Educators Association. Sick day management of adults with type 2 diabetes. Canberra: ADEA, 2014.