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INSUFFICIENT OR ABSENT INSULIN sick day management for Adults with Type  Diabetes

Muscle Fat Increased cells cells glucagon DKA (Diabetic Ketoacidosis) A deadly but avoidable complication sick dayof type management 1 diabetes and occasionally for Children with Typetype 2 diabetes  Diabetes Amino Glycerol Fatty acid acid WHAT IS DKA? CAUSES OF DKA CAN DKA is a series of events that INCLUDE: Converted starts with not having enough ■■ Infection or severe illness, which to ketones insulin for the present condition stresses the body and leads to Converted hyperglycemicand leads to a serious imbalance the need for more insulin to cor- to glucose MLIVER in the blood. When there is not rect high glucose levels. Hyperosmolarenough insulin,Syndrome many cells of the (HHS) GLYCOGENOLYSIS ■■ Forgetting or intentionally not body are starved for glucose (also Glycogen GLUCONEOGENESIS taking insulin to cover carbo- called blood sugar) and the body chain KETOGENESIS hydrates at mealtime. tries to make energy from other ■■ Interruption of insulin delivery products. This changes your when on an insulin pump. Increased ketone and blood to be more acidic. When ■■ glucose production that happens, your breathing can When a cannula (the little plas- become labored, you can become tic tube connecting you to your BLOOD VESSEL severely dehydrated and some insulin pump) gets either dis- people can go into a coma. lodged or kinked. When this happens, there is limited or no HOW IS DKA DIAGNOSED? Increased ketone and insulin getting into your body. glucose in bloodstream DKA is diagnosed when your The result is that DKA can hap- blood tests as more acidic than pen very quickly – in hours normal and ketones are present. rather than days. If your glu- Other changes that occur in your cose values do not come down body are changes in the level of after you give a correctional sodium and potassium. Generally, bolus, give a shot via pen or blood glucose levels are high with syringe for the correction and DKA, but not always, especially replace the insertion set or if you are dehydrated or sick. pod. Remember, just because

1 | Copyright © 2020 Association of Diabetes Care & Education Specialists. All rights reserved. Reproduction or republication strictly prohibited without prior written permission. Supported by the Sanofi Lexicon Alliance moderate or large, contact your SICK DAY SYMPTOMS OF DKA: diabetes team. If they are trace SICK DAY MANAGEMENT or small, give correctional insu- MANAGEMENT for Children n Very thirsty lin every 2-3 hours and drink for Adults with lots of fluid. with Type 1 n Frequent urination Type 1 Diabetes Diabetes Dka ■■ If you vomit or feel nauseated, Diabetic n Nausea and call your diabetes care team. Ketoacidosis vomiting Sometimes people go to the n Drowsy hospital thinking they have the flu but have been without ade- n Deep breathing quate insulin for some time and n  are in DKA. Or sometimes the you just replaced it, does NOT Fruity smell to the flu can lead to DKA, due to mean it is working! Recheck your breath stress and dehydration. Getting glucose in two hours after chang- n Stomach pain your flu shot each year will help ing your set. Note: Some people n Coma if not treated you stay healthy and possibly prefer a stainless-steel infusion avoid DKA. set because it does not kink. ■■ If you are on a SGLT2 oral med- ■■ When your insulin goes bad ication to help manage your because it became too hot or PREVENTION OF DKA: glucose levels, you can have too cold. This can happen ■■ ALWAYS TAKE YOUR INSULIN! DKA even if your glucose levels when, for example, your insulin If you are not eating, you do not are within the normal range. is left in a hot car or on a sunny need to take it for food, but you Therefore, it is especially windowsill or freezes due to need the background dose, important for you to test for being exposed to cold weather whether basal rate through the ketones if you are feeling ill. or your refrigerator tempera- pump or long-acting insulin Additionally, avoid taking your ture being too low. given via shot. If you are eating SGLT2 medication if you are ■■ Delayed diagnosis of diabetes foods that contain carbohy- dehydrated, planning on an – due the difficulty in deter- drates, you will need to cover endurance event (for example mine the cause of the symp- the carbohydrates with insulin. a marathon), are on a severe toms of type 1 diabetes – for ■■ Check your blood glucose fre- carbohydrate restriction or are example weight loss, thirst and quently, at a minimum before ill. It raises your risk of DKA. frequent urination are frequent every meal and prior to bed or ■■ If you are on an insulin pump signs and symptoms of the flu use a continuous glucose moni- and it is not working correctly, or urinary tract infection. tor (CGM) so you can recognize have a written back-up plan for when glucose levels are too multiple daily injections avail- high for longer periods of time able. As an example, you may (4 hours or longer). need long acting insulin plus ■■ Always have either urine keto short acting insulin or correc- sticks or a blood ketone monitor tional insulin every 3 hours until with your medical supplies. you receive a new insulin pump. This should be written out with ■■ If you cannot get your blood someone on your diabetes team glucose levels to come down BEFORE you are sick. below 240 mg/dl, make sure to check for ketones. If they are

2 | Copyright © 2020 Association of Diabetes Care & Education Specialists. All rights reserved. Reproduction or republication strictly prohibited without prior written permission. Supported by the Sanofi Lexicon Alliance SICK DAY SICK DAY MANAGEMENT MANAGEMENT for Children for Adults with with Type 1 Type 1 Diabetes Diabetes Dka Diabetic Ketoacidosis

IF YOU ARE IN DOUBT – CALL YOUR DIABETES TEAM! IF YOU KETONES IGNORE IT, DKA CAN BE DEADLY. WHEN SHOULD YOU Ketones are chemicals made in your liver. You make them when CHECK FOR KETONES? you don't have enough insulin in your body to turn glucose (sugar) into energy. Because your body needs energy from a ■■ If you are not pregnant and chemical like glucose, your body makes a “look alike” from fats. have type 1 diabetes, you These ketones can make you very sick. should test for ketones when- ever your glucose is over 300 mg/dl for several hours, espe- The goal is to have trace or no cially when you are sick. ketones with urine ketone ■■ If you are pregnant and have chart type 1 diabetes, you should test for ketones whenever your glu- cose is over 200 mg/dl. If you are on an insulin pump, you should check for ketones when-

ever your glucose is over 300 ketones mg/dl without a known reason, or if your blood sugar does not come down within two hours of giving a corrective insulin dose. The goal if you are using a

KETONE METER blood ketone meter is less than 0.6 mmol/L for blood Gen KETONE ketones 1.8 mmol/L

3 | Copyright © 2020 Association of Diabetes Care & Education Specialists. All rights reserved. Reproduction or republication strictly prohibited without prior written permission. Supported by the Sanofi Lexicon Alliance