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.