Ask the Doctor

Ask the Doctor

ASK
THE DOCTOR

by Wesley
W. Wilson, MD

NOTE: If you have any questions
for "Ask the Doctor," please send them to the VOICE editorial office.
The only questions Dr. Wilson will be able to answer are the ones used in this
column.

Wesley Wilson, MD is an Internal Medicine practitioner

at the Western Montana Clinic in Missoula, Montana. Dr.

Wilson was diagnosed with type I diabetes in 1956, during

his second year of medical school.

Q: When I am sick and can't keep food down, should I

skip my next insulin injection?

A: Your question is excellent, and points up an area

of uncertainty that gets a lot of folks with diabetes into

significant problems. Remember that a number of factors

raise blood sugar levels: Lack of insulin, infections, lack

of exercise... A profound deficiency of insulin (you

skipping a shot) certainly can cause a rise in blood sugar,

even if with no food intake.

A flu-like illness, with vomiting, can set the stage

for development of diabetic ketoacidosis, which is a serious

problem for folks with type I diabetes. Ketoacidosis (DKA)

can appear quite rapidly, and seems to be caused by a

combination of dehydration and lack of insulin effect. In a

flu-like illness, a person not able to take fluids is likely

to be dehydrated. If they omit their insulin dose, they are

particularly likely to have significant tissue lack of

insulin effect, which sets up the possibility of developing

diabetic ketoacidosis. The problem is that when you are

unable to eat, you may be fearful of taking insulin, as

there is no way you can counteract an excessively low blood

sugar, should it occur. You certainly don't want to have

an insulin reaction--"hypoglycemia"--when you cannot take in

food to get your blood sugar back up.

Flu-like illnesses with nausea and vomiting are almost

certain to occur during the lifespan of anyone with type I

diabetes. Therefore, it is important to discuss this problem

beforehand with your health care provider.

The single most important thing you can do is CHECK

YOUR BLOOD SUGAR MORE FREQUENTLY when you are ill than when

you are well. It's often a shock to folks who have not

taken food for a fairly long period of time to check their

blood sugar--they are surprised to find it higher than

normal, related to their illness and often to lack of

adequate insulin effect.

The standard treatment for illness with nausea and

vomiting in a person using insulin is first to check the

blood sugar. If it's high, take some dose of insulin, the

amount of which should be discussed with your health care

provider before the illness. Next, try to take some form of

fluid which does not contain carbohydrate calories--soda

pop, juice, apple juice. Anything with some calories and

fluid is helpful, and not likely to cause major problems as

long as the blood sugar is checked frequently. The dose of

insulin may require a change, but it is still essential, and

only by testing blood sugars frequently can you determine

what dose should be used.

Forewarned is forearmed! Plan for this problem in

advance. Each person may require a bit of individualized

approach, so it's important to work out the details of sick

day management, but the key thing is to check blood sugars

frequently during illness. If there are nausea, vomiting,

and elevated blood sugars, it's particularly important to

check the urine for acetone or ketones, so you should always

have a supply of acetone testing strips available for your

use. If protracted nausea and vomiting occur, receiving

intravenous fluids with some carbohydrate calories and with

some insulin coverage can often avoid serious consequences.