The Healing Handbook for Persons with Diabetes

Chapter 10: Sick Day Management

Sick Day Rules Sick Day Management at a Glance 
Adding Insulin 
Reducing Insulin 
A Sick Day Rules Diagram 
Oral Hypoglycemic Pills and Illness 
Food for Sick Days 
Nausea, Vomiting, and Diarrhea 
Nonprescription Medicines For When You Are Sick 

Many kinds of illnesses can disrupt your blood glucose control. Viral colds or flu, infections, injuries, fever, vomiting, and diarrhea all increase your need for insulin. Emotional stress and surgery can also affect blood glucose level. Learning to manage "sick days" at home can help you avoid hospitalization and make you feel more comfortable until your illness has passed.


  1. NEVER omit your insulin, even if you can't eat. You may need additional insulin, but do not take additional oral hypoglycemic pills.
  2. Test your blood sugar every 4 hours. If you need help, ask for it!
  3. If you have Type I Diabetes, test your urine for ketones every 4 hours.
  4. Drink clear liquids (at least ½ cup every hour), and eat light foods if you can.
  5. Rest. Do not exercise during an illness.
  6. Call your doctor or diabetes educator if:
    • You have an obvious infection
    • Your illness lasts longer than 2 days
    • You have vomiting or diarrhea more than 8 hours
    • Your blood sugar is over 400 mg in two consecutive tests
    • All urine tests are positive for large amounts of sugar
    • You have moderate to large urine ketones with a blood glucose level over 200 mg for more than 8 hours
    • You feel very ill or experience pain
    • You have extreme fatigue, shortness of breath, or dizziness

Adding Insulin 

When your blood sugar is high on sick days, add Regular insulin only. Additional Regular insulin helps your body use the sugar in blood and prevents breakdown of fat cells.

For blood sugar over 150 mg/dl, add 10% of your total daily dose as Regular insulin every 4-6 hours.

  • Here is an example: Blood sugar is 210 mg and urine ketones are negative.

    Total usual AM dose of insulin NPH
    22 units
    4 units
    Total usual PM dose of insulin NPH
    10 units
    4 units
    40 Units

  • 10% of the total dose = 4 units.
  • Add 4 units regular insulin to usual dose every 4-6 hours, when blood sugar is over 150 mg.

For blood sugar over 150 mg/dl PLUS moderate to large ketones in the urine, add 20% of your total daily dose as Regular insulin every 4-6 hours.

  • Example: Blood sugar is 300 mg, urine ketones - positive.

    Total usual AM dose of insulin NPH
    14 units
    2 units
    Total usual PM dose of insulin Regular
    4 units
    Total usual bedtime dose of insulin NPH
    10 units
    30 Units

  • 20% of the total dose = 6 units.
  • Add 6 units regular insulin to usual dose every 4-6 hours, when blood sugar is over 150 mg and urine ketones are positive.

Reducing Insulin 

  • When your blood sugar is below 150 mg and you are unable to eat meals due to nausea and vomiting, take only NPH or Lente insulin and no regular insulin.
  • Contact your diabetes educator or doctor if this occurs. They will provide guidance regarding how much of your usual NPH or Lente dose should be used.

A Sick Day Rules Diagram 

Sick Day Rules Diagram 

Oral Hypoglycemic Pills and Illness 

If you take oral hypoglycemic pills, you must watch for signs of low blood sugar during any illness that causes you to vomit or keeps you from eating and drinking normally. The hypoglycemic pills you took before your illness continue working to lower your blood sugar even when you do not increase it by taking in food. Try to replace missing carbohydrates by eating soup, crackers, or toast, or by drinking ginger ale or cola.

Test your blood glucose or urine every few hours. If your blood glucose levels are all below 120 or your urine tests are all negative for sugar, and you are shaky, nervous, sweaty, pale, weak, or dizzy, or have tingling or numbness in your hands or feet, call your doctor immediately or seek emergency assistance. You will need help to get through this time.

If you take pills for diabetes, watch out when you are sick! 

Food for sick days 

If you are too sick to follow your meal plan, try to replace carbohydrates with liquids or soft foods. Carbohydrates provide sugar so that the body does not have to burn fat for energy. Burning fat produces ketones, which can be dangerous. Carbohydrates also prevent blood sugar from dropping too low.

Small, frequent feedings may be easier for you to tolerate during an illness, and help your digestive system provide energy to your cells more quickly.

Try to drink 4 ounces of clear liquids such as tea, apple juice, or diet soda every hour.

If you can keep food down, but still have no appetite, try l/2 cup cream soup, 1/2 cup cooked cereal, 1 cup plain yogurt, Jell-O, 1/2 banana, 1 scrambled egg, 1/2 cup custard, or l/2 cup sherbet. Once you're feeling better, try adding toast, vanilla wafers, and small amounts of food from your regular meal plan. Avoid spicy foods.

Nausea, Vomiting, and Diarrhea 

When you experience these symptoms, take small pieces of crushed ice, or 1-2 ounces of regular cola or ginger ale (decarbonate by stirring) every 30 minutes.

If you can keep this down, try adding soup or broth, tea, and clear juices.

Soups and broths help to replace sodium and potassium lost through vomiting and diarrhea.

Nonprescription Medicines For When You Are Sick 

People with diabetes get colds, allergies, and upset stomachs, just like people without diabetes. Over-the-counter medicines for these ailments may contain ingredients that raise or lower blood glucose, or that mimic symptoms of high or low blood glucose.

Read the label before you purchase or use any over-the-counter medication. If there is a warning that people with diabetes should check with their doctors before using the product, do so. Some people with diabetes may be able to use the product, while others may not.

Here are some medications you can use:

For Coughing  Sorbutusess Syrup, Toclonol Expectorant
For Sore Throat  Cerose or Cerose DM, Scot-tussin
Decongestants  Afrin or Neo-Synephrine Nasal sprays (both may have opposite effect if overused), Afrinal, Chlortrimaton Tablets, Actifed, Sudafed, Drixoral
Allergy Products  Allerest, A.R.M Allergy Relief Medicine, Dimetapp Elixir, Contact (all these may cause drowsiness)
For Diarrhea  Pepto-Bismol, Kaopectate, Donogel, Parapectolin, Immodium
For Constipation  Konsyl, Kondremul, Agoral Neoloid, Phospho-soda, Milk of Magnesia, Colace, Metamucil (or any enema or suppository)
Antacids  Digel, Gelusil, Maalox, Mylanta, Riopan
Nausea/Vomiting  Coke syrup or Emitrol (products contain sugar, but may be used in moderation, especially when one is not eating)
Motion Sickness  Dramamine tablets, Scopolamine Patch, Bonine


  • Do not use appetite suppressants. Follow your diet and exercise plan to lose weight.
  • Large amounts of aspirin may interact with oral hypoglycemic agents, lowering blood sugar. A couple of aspirin now and then cause no harm for adults, however.

REMEMBER: The care of diabetes is a team effort involving you, your physician, and the diabetes education staff where you receive your medical care. This handbook cannot-and was not meant to-replace this team effort. 

This handbook embodies the approach of the diabetes care team at the University of Massachusetts Medical School. Different diabetes care teams may approach some aspects of diabetes care in ways that differ from those in this handbook. While most teams are in close agreement regarding the GENERAL PRINCIPLES of diabetes care, they may differ in the DETAILS. There can be more that one "right" way to approach a specific issue in diabetes management. 

Always remain in touch with your diabetes care team, and bring any questions you may have about the materials in this handbook to their attention! 

Note that these sick day rules may suggest that you take a lot of extra insulin. Bear in mind, however, that they are meant only for when you are SICK and your blood sugar is HIGH. Frequent blood sugar monitoring (every 2 to 4 hours) is essential. During illness extra insulin is almost always needed. If you are uncomfortable with these rules, especially if you are treating a child, you may wish to use a little less than the rule suggests for the first few doses. 

Copyright 1995, 1996, 1997, 1998 Ruth E. Lundstrom, R.N., John P. Mordes, M.D., Aldo A. Rossini, M.D. All rights reserved.
Feedback: send e-mail to Dr. Aldo Rossini.