Tips for Sick Day Management in Type 1 Diabetes

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Managing type 1 diabetes during illness requires careful attention and proactive strategies. When you’re sick, your body undergoes significant stress that can dramatically affect blood sugar levels, making diabetes management more complex and potentially dangerous. Understanding how to navigate sick days is essential for preventing serious complications like diabetic ketoacidosis (DKA) and maintaining your health during recovery.

When your body releases hormones to fight illness, it can also raise your blood sugar levels. This physiological response means that even routine illnesses like colds, flu, or infections can create unpredictable blood glucose patterns. When you get sick with a cold, flu, or an infection, your body is under stress and insulin does not work as well in your body’s cells and your blood sugar levels can be higher. This comprehensive guide will help you develop effective sick day management strategies to stay safe and maintain control of your diabetes when illness strikes.

Understanding How Illness Affects Type 1 Diabetes

Illness and stress are common occurrences, and for the person with type 1 diabetes, these events can be triggers for counterregulation and subsequent metabolic deterioration if there is no attention to diabetes management tasks. The relationship between illness and blood sugar is complex and often counterintuitive.

During times of infections or fever, blood glucose levels tend to increase while in times of nausea/vomiting and diarrhea, blood glucose levels might decrease. This variability makes sick day management particularly challenging, as you may need to adjust your approach based on the type of illness you’re experiencing.

This can happen even if you are taking normal doses of your medications, including insulin. The stress hormones released during illness can cause insulin resistance, meaning your usual insulin doses may not be as effective as they normally are. This is why many people with type 1 diabetes require more insulin during illness, even if they’re eating less than usual.

Creating Your Sick Day Action Plan

Before you get sick, it’s crucial to work with your healthcare team to develop a personalized sick day management plan. Discuss with your provider, before you are sick, how best to handle illnesses. This proactive approach ensures you’ll know exactly what to do when illness strikes, reducing stress and improving outcomes.

Essential Components of a Sick Day Plan

Your sick day plan should include specific instructions for insulin adjustments, target blood sugar ranges during illness, ketone testing protocols, and clear guidelines about when to contact your healthcare provider or seek emergency care. Keep this plan easily accessible, and make sure family members or caregivers know where to find it.

Document your healthcare provider’s contact information, including after-hours numbers. Make sure your family members also know the warning signs. Having this information readily available can be lifesaving during a diabetes emergency.

Building a Sick Day Supply Kit

Make sure you have insulin, other diabetes medicines, and easy-to-make foods, enough for several weeks or longer, and consider having these medicines and supplies in your home. A well-stocked sick day kit should include:

  • Extra insulin and diabetes medications
  • Ketone testing strips (urine or blood)
  • Blood glucose testing supplies
  • Thermometer
  • Pain reliever and fever reducer
  • Anti-nausea medication
  • Antacid
  • Anti-diarrheal medication
  • Easy-to-digest foods and beverages
  • Sugar-free fluids for hydration
  • Regular soda or juice for treating low blood sugar

Some examples of foods you may want on hand include sports drinks, canned soup, fruit juice or regular soda, instant cooked cereals, crackers, instant pudding, and unsweetened applesauce. These foods are gentle on the stomach and provide necessary carbohydrates when you may not feel like eating regular meals.

Monitoring Blood Sugar Levels During Illness

Frequent blood glucose monitoring becomes even more critical when you’re sick. Check your blood sugar more often than usual (every 2 to 4 hours). This increased frequency helps you detect trends and make timely adjustments to prevent both hyperglycemia and hypoglycemia.

If you’re using a CGM, closely monitor your levels, or check your blood-glucose every 2 to 4 hours with a glucometer. Continuous glucose monitors can be particularly valuable during illness, as they provide real-time data and alert you to rapid changes in blood sugar levels.

Recording Your Results

Write down or record all your blood sugar levels, the time of each test, and the medicines you have taken. Detailed records help you identify patterns and provide valuable information to your healthcare team if you need to contact them. Note any symptoms you’re experiencing, what you’ve eaten, and how much insulin you’ve taken.

Try to keep your blood sugar at less than 200 mg/dL (11.1 mmol/L), and there may be times when you need to check your blood sugar every hour. If your blood sugar is consistently high or you’re having difficulty managing levels, more frequent monitoring may be necessary.

The Critical Importance of Ketone Testing

Ketone testing is one of the most important aspects of sick day management for people with type 1 diabetes. Ketones are produced when the body burns fat for energy or fuel, and they are also produced when you lose weight or if there is not enough insulin to help your body use sugar for energy.

When to Test for Ketones

If you take insulin, do a test for ketones, especially when you have high blood sugar. Specific situations that warrant ketone testing include:

  • Anytime your blood glucose is over 250 mg/dl for two tests in a row
  • When you are ill
  • When you’re experiencing nausea or vomiting
  • When you have abdominal pain
  • If you’ve missed insulin doses
  • During pregnancy

If you have type 1 diabetes, check your urine ketones every time you urinate. This frequent testing during illness helps catch rising ketone levels early, before they become dangerous.

Understanding Ketone Test Results

Monitoring blood ketones is preferred over urine ketones because it provides more precise information about your ketone levels. However, urine ketone strips are more affordable and widely available, making them a practical option for many people.

Readings below 0.6 mmol/l are in the normal range. If your ketones are in this range, continue monitoring but no immediate action is typically needed beyond your regular diabetes management.

Readings between 0.6 and 1.5 mmol/L may indicate the start of a problem that may require medical assistance. At this level, you should increase fluid intake, take additional insulin as directed by your sick day plan, and retest in a few hours.

Readings above 1.5 mmol/L indicate that you are at risk of developing diabetic ketoacidosis (DKA), and you should call your diabetes team immediately for advice. This is a medical emergency that requires prompt intervention.

Blood Versus Urine Ketone Testing

Ketones have traditionally been measured via urine or blood, and blood ketone measurement is a valuable tool to prevent DKA, given that the rise in blood ketones may precede the rise in urine ketones. Blood ketone meters provide more accurate, real-time information about your current ketone levels.

Because urine may have been in the bladder for some time, the results from urine tests may show levels that are either higher or lower than the ketone levels currently circulating in your body. Despite this limitation, urine testing remains a valuable and accessible option for ketone monitoring.

Understanding Diabetic Ketoacidosis (DKA)

Vomiting in a patient with type 1 diabetes is a medical emergency, and vomiting can be sign of diabetic ketoacidosis (DKA), which is a very serious complication of type 1 diabetes. Understanding DKA and recognizing its early warning signs can be lifesaving.

What Causes DKA

DKA happens when insufficient insulin leads to a buildup of acid (ketones) in the blood. Without adequate insulin, your body cannot use glucose for energy and begins breaking down fat at a rapid rate. Without enough insulin, glucose builds up in the blood, and since the body is unable to use glucose for energy, it breaks down fat instead, and when this occurs, ketones form in the blood and spill into the urine.

The most common type of ketoacidosis is a complication of diabetes called diabetic ketoacidosis (DKA), which is a medical emergency that often develops quickly and can lead to a coma and be life-threatening. This is why early detection and treatment are so critical.

Recognizing DKA Symptoms

Early recognition of DKA symptoms allows for prompt treatment and can prevent progression to a life-threatening emergency. Common symptoms include:

  • Excessive thirst
  • Frequent urination
  • Nausea and vomiting
  • Abdominal pain
  • A “fruity” smell to the breath
  • Rapid breathing
  • Confusion or difficulty concentrating
  • Extreme fatigue
  • Flushed skin

Talk to your doctor immediately if your urine results show moderate or large amounts of ketones, as this is a sign that your diabetes is out of control, or that you are getting sick. Don’t wait to see if symptoms improve on their own—DKA requires immediate medical attention.

Insulin Management During Illness

Insulin must be taken every day, even when you are sick. This is one of the most important rules of sick day management. Never skip your insulin doses, even if you’re not eating normally or your blood sugar is lower than usual.

Why You Need Insulin When Sick

It is important to keep taking your insulin. Even if you’re not eating, your body still needs basal insulin to prevent ketone production. If you take insulin, being sick may affect how much you need, and if your body doesn’t have enough insulin, it starts breaking down fat as fuel, which produces a byproduct called ketones.

Your insulin requirements may change on sick days, and infections such as strep throat may require higher insulin doses, whereas illnesses that cause vomiting and diarrhea may require less insulin than usual. This is why having a sick day plan and staying in close contact with your healthcare team is essential.

Adjusting Insulin Doses

If you don’t have a sick-day plan for taking extra insulin, call your doctor for advice. Your healthcare provider can guide you on how much additional rapid-acting insulin to take based on your blood sugar and ketone levels.

Your child may need extra insulin when sick. This applies to adults as well—illness often increases insulin requirements significantly. If tests show your child has ketones, they’ll need extra insulin to clear their ketones and minimize their risk of diabetic ketoacidosis (DKA).

People on insulin may need extra short-acting or rapid-acting insulin if blood sugar is 300 or higher. Your sick day plan should include specific correction doses based on your blood sugar and ketone levels. Always wait at least 2-3 hours between correction doses to avoid insulin stacking, which can lead to dangerous low blood sugar.

Special Considerations for Insulin Pump Users

Pump users should have a low threshold for changing pump sites anytime a child has ketones. During illness, insulin absorption may be affected, and pump site problems can develop more quickly. If ketones are present or blood sugars are persistently high, consider changing your infusion site and delivering correction doses via injection rather than through the pump.

If you wear an insulin pump, do not take off your pump unless you will be taking insulin shots while you are off the pump. Never go without insulin, even for short periods, as this can rapidly lead to ketone development and DKA.

Nutrition and Hydration Strategies

Maintaining adequate nutrition and hydration during illness is crucial for diabetes management and recovery. Drink extra fluids to prevent dehydration. Dehydration can worsen high blood sugar and increase the risk of DKA.

Staying Hydrated

Drink plenty of fluids—staying hydrated is critical, and if you cannot keep fluids down due to vomiting, visit your nearest emergency department immediately. Dehydration combined with high blood sugar and ketones creates a dangerous situation that requires immediate medical intervention.

Beverages, such as water or other sugar-free fluids, will help prevent dehydration and flush out the ketones. When blood sugar is elevated, focus on sugar-free beverages like water, sugar-free sports drinks, broth, or herbal tea. Avoid drinks with caffeine.

If your blood sugar level is higher than the level your doctor recommends (for example, 240 mg/dL), drink extra liquids that don’t contain sugar, such as water or sugar-free cola. However, if your blood sugar is low or normal and you’re having difficulty eating, you may need beverages that contain carbohydrates.

Managing Fluid Intake with Vomiting

If your child is vomiting, even small amounts of fluids can help, and you should start by giving 1 tablespoon of fluid every 5 to 10 minutes (about 3 ounces per hour). This approach applies to adults as well. Small, frequent sips are often better tolerated than trying to drink large amounts at once.

Talk with your doctor about a prescription for anti-nausea/antiemetic medication like ondansetron (Zofran) to have on hand for sick days. Having anti-nausea medication available can help you keep fluids down and prevent dehydration.

Eating During Illness

Try to eat your normal types and amounts of food. If you can maintain your regular eating pattern, this makes diabetes management more predictable. However, when you’re sick, this isn’t always possible.

If you can’t eat meals, you’ll need to eat or drink about 50 grams of carbohydrates every 4 hours, and some examples include 1½ cup of unsweetened applesauce or 1½ cup of fruit juice. This guideline helps ensure you’re getting enough carbohydrates to prevent low blood sugar while providing your body with energy.

A general guideline is to try to eat or drink 50 grams of carbohydrate every 3 to 4 hours, and for example, 6 saltine crackers, 1 cup (8 ounces) of milk, and ½ cup (4 ounces) of orange juice each have about 15 grams of carbohydrate. Choose foods that are easy to digest and gentle on your stomach.

Eat small meals often. Even if you don’t have much appetite, try to consume small amounts of carbohydrates regularly throughout the day. Good options include:

  • Crackers
  • Toast
  • Applesauce
  • Soup or broth
  • Gelatin
  • Popsicles
  • Regular soda or juice (if blood sugar is low or normal)
  • Sports drinks
  • Instant oatmeal or cream of wheat

It’s important to nibble on some crackers or slowly sip some carbohydrates to prevent ketone development. Even when you don’t feel like eating, maintaining some carbohydrate intake helps prevent your body from breaking down fat for energy, which produces ketones.

Medication Considerations During Illness

Be careful with over-the-counter medicines, don’t take any nonprescription medicines unless you talk to your doctor first, and many nonprescription medicines can affect your blood sugar level. This is an important consideration that many people overlook.

Over-the-Counter Medications

Many common cold and flu medications contain ingredients that can raise blood sugar levels. Decongestants, cough syrups with sugar, and some pain relievers can all affect glucose control. Always check labels and consult with your pharmacist or healthcare provider before taking any new medication.

Choose sugar-free versions of cough syrups and liquid medications when available. Read labels carefully, as some “sugar-free” products may still contain carbohydrates that can affect blood sugar. Keep a list of medications that your healthcare provider has approved for use during illness.

Continuing Diabetes Medications

Take your usual dose of insulin or diabetes pills. Continue all your regular diabetes medications unless specifically instructed otherwise by your healthcare provider. If you don’t take insulin, continue to take your diabetes medications, even if you are sick and have been throwing up.

Carbohydrates must be taken every day, even when you are sick, and try to eat as much of your usual diet as possible. This helps your diabetes medications work effectively and prevents dangerous blood sugar fluctuations.

When to Contact Your Healthcare Provider

Minor illnesses in people with diabetes (especially children with type 1 diabetes) can lead to very high blood sugar levels and possible emergencies. Knowing when to seek help is crucial for preventing serious complications.

Warning Signs Requiring Medical Attention

Contact your healthcare provider immediately if you experience any of the following:

  • Blood sugar higher than 240 mg/dL (13.3 mmol/L) for more than 1 day
  • Moderate-to-large ketones with your urine tests
  • Vomiting or diarrhea for more than 4 hours
  • Any severe pain or chest pain
  • A fever of 100°F (37.7°C) or higher
  • Trouble moving your arms or legs
  • Vision, speech, or balance problems
  • Confusion or new memory problems

Glucose remains above 300 mg/dL for more than six hours or below 70 mg/dL after repeated treatment. Persistent high or low blood sugar that doesn’t respond to treatment requires medical evaluation.

If vomiting occurs and blood sugar is over 200 mg/dl, please dip urine for ketones, and if ketones, abdominal pain, or vomiting are present, please call us immediately so that we can help manage the situation and determine if the patient needs to go to the hospital.

When to Go to the Emergency Room

This is particularly important if you are vomiting or have diarrhea for more than 4 hours. Prolonged vomiting or diarrhea can quickly lead to dehydration and DKA in people with type 1 diabetes.

If you are unable to reach your diabetes care team, head for the emergency room or an urgent care facility. Don’t hesitate to seek emergency care if you’re concerned about your condition. It’s always better to be evaluated and sent home than to wait too long and develop serious complications.

Being sick and/or having a low blood sugar level can cause fatigue or difficulty thinking clearly, and if needed, have someone else call your doctor or take you to the emergency room to avoid unsafe driving. Never drive yourself to the hospital if you’re experiencing confusion, severe symptoms, or very low blood sugar.

Special Considerations for Different Types of Illness

Different illnesses affect blood sugar in different ways, requiring tailored management approaches. Understanding these differences helps you anticipate challenges and adjust your diabetes care accordingly.

Respiratory Infections and Fever

Respiratory infections like colds, flu, and sinus infections typically cause blood sugar to rise due to the stress response and inflammation. More severe colds could lead to high blood sugar. You’ll likely need more insulin than usual, even if you’re eating less.

Fever increases metabolic rate and insulin resistance, often requiring significant increases in insulin doses. Monitor blood sugar and ketones closely, and don’t hesitate to contact your healthcare provider for guidance on insulin adjustments.

Gastrointestinal Illness

Stomach bugs with nausea, vomiting, or diarrhea present unique challenges. Blood sugar may drop if you’re unable to eat or keep food down, but the stress of illness can also cause blood sugar to rise. This unpredictability requires very frequent monitoring.

Focus on staying hydrated and maintaining some carbohydrate intake, even if it’s just small sips of juice or sports drinks. Continue your basal insulin, but you may need to adjust mealtime insulin based on what you’re able to eat and your blood sugar levels.

Minor Illnesses

You may not see much impact on your blood-glucose levels. Very mild colds or minor illnesses may not significantly affect your diabetes management. However, continue monitoring closely, as illnesses can worsen quickly.

If you’re lying low on the couch, the decrease in physical activity can also call for a bit more insulin. Even if the illness itself isn’t affecting your blood sugar much, reduced activity levels can lead to higher glucose levels.

Exercise and Physical Activity During Illness

Exercise is often a good way to bring down high blood glucose—but not when ketones are present, and never exercise when your urine checks show moderate or large amounts of ketones and your blood glucose is high. This is a critical safety rule.

Do not exercise if your blood glucose is over 250 mg/dl and ketones are present. Exercise when ketones are present can worsen ketoacidosis and lead to dangerous complications. It may make your blood glucose level go even higher.

In general, it’s okay to exercise with trace or small ketones, but if ketone levels are moderate or large, exercise should be delayed until ketone levels are lower. When you’re sick, rest is usually more beneficial than exercise. Focus on recovery, and return to your normal activity level once you’re feeling better and your blood sugar and ketones are under control.

Preparing for Sick Days: A Proactive Approach

The best time to prepare for sick days is when you’re healthy. Taking proactive steps ensures you’ll be ready to manage your diabetes effectively when illness strikes.

Education and Training

People with diabetes, their families and/or caregivers must receive education and be given access to guidelines preparing them for managing diabetes during illness. Make sure everyone involved in your care understands your sick day plan and knows how to help in an emergency.

Practice ketone testing when you’re well so you’re familiar with the process. Know how to interpret results and what actions to take based on different ketone levels. Review your sick day plan regularly with your healthcare team and update it as needed.

Maintaining Supplies

Regularly check your sick day kit to ensure supplies haven’t expired. Urine test strips degrade over time, and if you are using urine ketone strips, look at expiration dates carefully and discard containers open longer than 6 months. Replace expired items promptly.

Keep extra insulin on hand, and make sure you have backup supplies for your blood glucose meter and continuous glucose monitor if you use one. Having redundant supplies ensures you won’t run out during illness when getting to the pharmacy may be difficult.

Communication with Healthcare Team

Work with your diabetes care team to develop a plan for managing your T1D while sick, and always stay in close contact with your diabetes care team and seek emergency care if you can’t manage things at home. Establish clear communication channels and know how to reach your healthcare provider after hours.

Don’t hesitate to call with questions or concerns. Call our center, if you have any questions or concerns regarding being ill and your diabetes—it is better to contact us, than to wait until you become very ill. Early intervention can prevent minor problems from becoming serious emergencies.

Long-Term Strategies for Better Sick Day Management

Improving your overall diabetes management makes sick days easier to handle. Good baseline control means you’re starting from a better position when illness strikes.

Optimizing Daily Diabetes Management

Work toward achieving target blood sugar ranges most of the time. Better baseline control reduces the risk of DKA during illness and makes blood sugar fluctuations less extreme. Regular follow-up with your healthcare team, proper insulin dosing, consistent carbohydrate counting, and appropriate physical activity all contribute to better overall control.

Consider using diabetes technology like continuous glucose monitors and insulin pumps if appropriate for your situation. These tools can provide valuable data and make management easier both during routine days and sick days.

Preventing Illness

While you can’t prevent all illnesses, you can reduce your risk through good health practices. Get recommended vaccinations, including annual flu shots and COVID-19 vaccines. Practice good hand hygiene, get adequate sleep, manage stress, and maintain a healthy diet to support your immune system.

People with diabetes may be at higher risk for certain infections and may experience more severe illness. Taking preventive measures is an important part of diabetes care.

Learning from Each Experience

After recovering from illness, review what happened with your healthcare team. What worked well? What could be improved? Did you need to adjust insulin doses, and if so, by how much? This information helps refine your sick day plan for future illnesses.

Keep detailed records during sick days, including blood sugar readings, ketone levels, insulin doses, food and fluid intake, and symptoms. These records provide valuable information for adjusting your management plan and can help your healthcare team provide better guidance.

Resources and Support

Managing type 1 diabetes during illness can feel overwhelming, but you don’t have to do it alone. Numerous resources and support systems are available to help you navigate sick days successfully.

Organizations like the American Diabetes Association, Breakthrough T1D, and the Centers for Disease Control and Prevention provide comprehensive information about diabetes management during illness. These organizations offer educational materials, support groups, and resources for people with diabetes and their families.

Connect with other people living with type 1 diabetes through online communities and local support groups. Sharing experiences and learning from others who face similar challenges can provide valuable insights and emotional support.

Consider working with a certified diabetes care and education specialist (CDCES) who can provide personalized education and help you develop effective sick day management strategies. These specialists can teach you advanced diabetes management skills and help troubleshoot problems.

Conclusion: Empowering Yourself for Sick Day Success

Effective sick day management is a critical skill for everyone living with type 1 diabetes. While illness adds complexity to diabetes care, having a solid plan and understanding what to do can help you navigate these challenges safely and confidently.

Remember the key principles: monitor blood sugar and ketones frequently, never skip insulin doses, stay hydrated, maintain carbohydrate intake when possible, and know when to seek medical help. Prepare in advance by creating a sick day kit, developing a detailed action plan with your healthcare team, and ensuring family members understand how to help.

Every person with type 1 diabetes will face sick days—it’s not a matter of if, but when. By preparing now and following evidence-based sick day management guidelines, you can minimize complications, prevent DKA, and recover more quickly. Don’t hesitate to reach out to your healthcare team with questions or concerns. They’re there to support you, and early intervention is always better than waiting until problems become severe.

With knowledge, preparation, and appropriate support, you can successfully manage your diabetes during illness and maintain your health and well-being. Stay informed, stay prepared, and remember that you have the tools and resources needed to handle sick days effectively.