Most acute deterioration in a stable outpatient with diabetes is not a failure of the regimen. It is what happened during three days of fever, vomiting or diarrhoea, when nobody had told the patient what to do.
The rules are short enough to say in a minute. Never stop insulin, even when not eating — requirements usually rise. Check glucose more often, and ketones if type 1 or on an SGLT2 inhibitor. Hold the SGLT2 inhibitor, metformin, ACE inhibitor or ARB, and diuretic while dehydrated or vomiting, and restart when eating and drinking normally. Keep drinking. Seek help for persistent vomiting, ketones, or glucose that will not come down.
Euglycaemic ketoacidosis is the trap this prevents. A patient on an SGLT2 inhibitor with vomiting and a glucose of 11 mmol/L can be in ketoacidosis, and both the patient and the first clinician who sees them may be reassured by the number. Write the sick-day rules down, in the language the patient reads, and check at the next visit whether they still have the paper.
- Never stop insulin during illness — requirements usually rise, not fall
- Hold SGLT2 inhibitor, metformin, ACE inhibitor or ARB, and diuretic while dehydrated or vomiting
- Check ketones in type 1 diabetes or on an SGLT2 inhibitor, whatever the glucose reading
- Euglycaemic ketoacidosis is missed because the glucose looks acceptable
- Give the rules in writing in the patient's own language and check they still have them
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