Principles of managing adults with diabetes and acute illness

Acute illness in a patient with diabetes can lead to rapid deterioration of the glycaemic profile. Either hyperglycaemia or hypoglycaemia can occur.

Hyperglycaemia, and consequent dehydration, can result from increased secretion of counter-regulatory hormones such as glucagon, cortisol and adrenaline. If not recognised and managed appropriately, this can result in severe hyperglycaemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemia or other adverse outcomes.

Hypoglycaemia can also occur, particularly with illness causing nausea, vomiting, diarrhoea or decreased oral intake. Gastroenteritis can be particularly problematic for patients with diabetes, causing both hypoglycaemia and hyperglycaemia.

All patients with type 1 diabetes and most with type 2 diabetes should have an individualised, written sick-day management plan, including contact numbers for emergency assistance and directions for when to go to hospital. With care and close medical support, most patients do not need hospitalisation during an acute illness.

Severe hyperglycaemia, complications of DKA and hyperosmolar hyperglycaemia can be caused by:

• systemic infection or major organ disorders (eg acute coronary syndromes)
• acute stress, psychiatric illness, or conditions causing cognitive impairment. These may lead to missed insulin doses, which can precipitate severe hyperglycaemia and DKA or hyperosmolar hyperglycaemia
• drugs given to treat an acute illness (eg glucocorticoids); see Glucocorticoid-induced hyperglycaemia.

Management of hyperglycaemia in patients with diabetes includes:

• urgent referral to hospital if hyperglycaemia is severe or worsening, or for persistent vomiting (regardless of presence of hypoglycaemia, ketosis or severe hyperglycaemia); see also Symptoms indicating a patient with diabetes and an acute illness needs hospital referral
• investigation and treatment of any underlying acute illness
• review of the patient’s usual antihyperglycaemic treatment and the potential for dose escalation
• consideration of short-term use of insulin, if feasible, in patients with type 2 diabetes and severe hyperglycaemia who do not usually use insulin.