When you experience vomiting, nausea, fever, diarrhea, or any form of infection, you should immediately contact your physician. I can’t emphasize enough the importance of getting treatment and getting it fast. To drive home this point, I’ll share the following experience.
Some years ago, I got a call from a woman at about four o’clock on a Sunday afternoon. She wasn’t my patient, but her diabetologist was out of town for the weekend with no backup for emergencies. He had never taught her what I teach my patients—the contents of this chapter.
She found my Diabetes Center in the white pages of the phone book. She was alone with her toddler son and had been vomiting continuously since 9 A.M. She asked me what she could do. I told her that she must be so dehydrated that her only choice was to get to a hospital emergency room as fast as possible for intravenous fluid replacement. While she dropped off her son with her mother, I called her local hospital and told them to expect her. I got a call 5 hours later from an attending physician. He had admitted her to the hospital because the emergency room couldn’t help her. Why not? Her kidneys had failed from dehydration. Fortunately, the hospital had a dialysis center, so they put her on dialysis and gave her intravenous saline (salt solution). Had dialysis not been available, she would likely have died. As it turned out, she spent 5 days in the hospital.
Clearly, a dehydrating illness is not something to take lightly, not a reason to assume your doctor is going to think you’re a hypochondriac if you call every time you have one of the problems discussed in this chapter. This is something that could kill you, and you need prompt treatment.
Why is it, then, that diabetics have a more serious time with dehydrating illness than nondiabetics? Clearly it has something to do with blood sugars.
If you are vomiting or have diarrhea, you’ve either been poisoned (unlikely) or have an infectious illness. If you have an infection, whether it’s in your mouth, on your finger, or in your gastrointestinal tract, your blood sugar is most likely going to go up. So you’re starting off with elevated blood sugars just by virtue of the infection. If you vomit or have diarrhea, you are losing fluid from a region in the body that normally contains fluid. That lost fluid is going to be replaced from the largest source of fluid in the body, the bloodstream. It’s not that you’re going to bleed into your stomach—your GI tract is full of blood vessels that are there in part for the exchange of fluids. That’s how fluid is absorbed.
Your body naturally tries to maintain a balance, so when fluid disappears from one place, your body tries to replace it using water from your bloodstream. But as water diffuses out of your blood, glucose is left behind, and you end up with a higher blood sugar. In addition, blood vessels are a giant web throughout the body, but unlike a web, the vessels narrow as they travel out from the center, narrowing from inside the body to outside, from inside an organ to its surface, and so on. At any given time, much of the blood is in these narrow, peripheral vessels.
If your bloodstream has lost significant amounts of fluid, as you would in a dehydrating illness, the periphery is not going to be as well supplied as it would normally be. It’s like having a whole new insulin resistance simply because insulin and glucose aren’t adequately reaching the narrower vessels. Since less glucose will be delivered to the cells adjoining these vessels, your blood sugar concentration will continue to climb. Furthermore, the higher your blood sugars go, the more insulin resistance you will experience. The more insulin-resistant you are, the higher your blood sugars are going to be. A vicious circle.
To make the circle even more vicious, when you have high blood sugars, you urinate—and of course what happens then is that you get even more dehydrated and more insulin-resistant and your blood sugar goes even higher. Now your peripheral cells have a choice—either die from lack of glucose and insulin or metabolize fat. They’ll choose the latter. But ketones are created by fat metabolism, causing you to urinate even more to rid yourself of the ketones, taking you to a whole new level of dehydration.
This sequence of events can happen in a matter of hours, as it did with the woman just described. So the name of the game is prevention.
How do you prevent illness from causing dehydration? Let’s say you wake up in the middle of the night or in the morning and vomit or have a bout of diarrhea. What do you do? Call your physician and let him or her know—even if it’s two o’clock in the morning, call your doctor. Even if it turns out to be just something you ate and it’s a transient episode, call your doctor or the emergency medical service.
We all get sick from time to time, but if you’re on our diet and treatment plan, and if you’re reasonably healthy, you shouldn’t get sick any more frequently than the average person (unless you have CVID; see here)—and probably less frequently than the average diabetic. For diabetics, however, such illness can pose special problems.
As you know, sickness or infection can cause your blood sugar to increase, and injected insulin—even if you don’t normally take insulin—can help preserve beta cell function during illness (as well as help keep your blood sugar under control and thereby reduce dehydration). One of the most pressing concerns for diabetics during illness is dehydration, which, as illustrated above, can lead to life-threatening consequences if not handled effectively and rapidly.
Common causes of dehydration include multiple episodes of diarrhea or vomiting; fever with resulting perspiration; failure to drink adequate fluids, especially during hot weather or prolonged exercise; and very high blood sugars. You probably know that one of the hallmark symptoms of very high blood sugars is the combination of extreme thirst and frequent urination. From what you’ve already read in this chapter, you should understand the equation. Still, I think it’s noteworthy enough to lay it out again for emphasis.
Dehydration causes transitory insulin resistance.*
During periods of dehydration, blood sugar will tend to rise.
High blood sugar, as you know, itself leads to insulin resistance and further blood sugar increase.
Blood sugar elevation from dehydration in addition to blood sugar elevation caused by the viral or bacterial infection that led to your vomiting, fever, or diarrhea causes further insulin resistance and blood sugar elevation.
High blood sugar causes further dehydration as your kidneys attempt to unload glucose and ketones by producing large amounts of urine.
Increased dehydration causes higher blood sugars, which in turn cause further dehydration. All of which brings us back to number 1.
The good news is, however, that simple interventions can halt this spiraling of blood sugars and fluid loss. It’s the purpose of this chapter to give you the knowledge to prevent the sort of grave consequences experienced by the lady who called me on that Sunday afternoon—or worse, death.
There are two acute conditions that can develop from the combination of high blood sugars and dehydration. The first is called diabetic ketoacidosis, or DKA. It occurs in people who make virtually no insulin on their own (either type 1 diabetics or type 2 diabetics who have lost nearly all beta cell activity). Very low serum insulin levels, combined with the insulin resistance caused by high blood sugars and dehydration, result in the virtual absence of insulin-mediated glucose transport to the tissues of the body. In the absence of adequate insulin, the body metabolizes stored fats to produce the energy that tissues require to remain alive. A by-product of fat metabolism is the production of substances called ketones and ketoacids. One of the ketones, acetone, is familiar as the major component of nail polish remover. Ketones may be detected in the urine by using a dipstick such as Ketostix (see Chapter 3, “Your Diabetic Tool Kit”). Ketones may also be detected on the breath as the aroma of an organic solvent, which is why unconscious diabetics are often mistaken for passed-out drunks.
Ketones and ketoacids are toxic in very large amounts. More important, your kidneys will try to eliminate them with even more urine, thereby causing further dehydration. Some of the hallmarks of severe ketoacidosis are large amounts of ketones in the urine, extreme thirst, dry mouth, nausea, frequent urination, deep labored breathing, and high blood sugar (usually over 350 mg/dl).
The other acute complication of high blood sugar and dehydration, hyperosmolar coma, is a potentially more severe condition, and occurs in people whose beta cells still make some insulin. (“Hyperosmolar” refers to high concentrations of glucose, sodium, and chloride in the blood due to inadequate water to dilute them.) Diabetics who develop this condition usually have some residual beta cell activity, making enough insulin to suppress the metabolism of fats, but not enough to prevent very high blood sugars. As a result, ketones may not appear in the urine or on the breath. Because this condition most commonly occurs in elderly people, who do not become very thirsty when dehydrated, the degree of dehydration is usually greater than in ketoacidosis. Early symptoms of a hyperosmolar state include somnolence and confusion. Extremely high blood sugars (as great as 1,500 mg/dl) have been reported in cases of hyperosmolar coma. Fluid deficit may become so severe that the brain becomes dehydrated. Loss of consciousness and death can occur in both the hyperosmolar state and in severe DKA.
The treatment for DKA and hyperosmolar coma includes fluid replacement and insulin. Fluid replacement alone can have a great effect upon blood sugar because it both dilutes the glucose level in the blood and permits the kidneys to eliminate excess glucose. Fluid also helps the kidneys eliminate ketones in DKA. Our interest here, though, is not in treating these conditions—this must be done by a physician or in a hospital—but in preventing them.
Vomiting, nausea, and diarrhea are most commonly caused by bacterial or viral infections sometimes associated with flulike illness. An essential part of treatment is to stop eating. Since you can certainly survive a few days without eating, this should pose no problem. But if you’re not eating, it makes sense to ask what dose of insulin or ISA you should take.
If you’re on one of the medication regimens described in this book, the answer is simple: you take the amount and type of medication that you’d normally take to cover the basal, or fasting, state and skip any doses that are intended to cover meals. If, for example, you ordinarily take Levemir, Lantus, or NPH as basal insulin upon arising and at bedtime, and a rapid-acting insulin before meals, you’d continue the basal insulin and skip the preprandial rapid-acting insulin for those meals you won’t be eating. Similarly, if you take an ISA on arising and/or at bedtime for the fasting state, and again to cover meals, you skip the doses for those meals that you do not plan to eat.
In both of the above cases, it’s essential that the medications used for the fasting state continue at their full doses. This is in direct contradiction to traditional “sick day” treatment, but it’s a major reason why patients who carefully follow our regimens should not develop DKA or hyperosmolar coma when they are ill.
Of course, if you’re vomiting, you won’t be able to keep down oral medication and this poses yet another problem.
Remember, because infection and dehydration may each cause blood sugar to increase, you may need additional coverage for any blood sugar elevation. Such additional coverage should usually take the form of rapid-acting insulin. This is one of the reasons that we advocate the training of all diabetics in the techniques of insulin injection—even those who, when not sick, can be controlled by just diet and ISAs. Using insulin when you’re sick may be especially important for you, because it helps to relieve the added burden on beta cells that leads to burnout. This is but one of the reasons it’s mandatory that you contact your physician immediately when you feel ill. He or she should be able to tell you how much coverage with insulin will be necessary, and when to take it. The protocol for such coverage is discussed here, but because of its importance, it bears repeating here briefly:
Measure blood sugars on arising and every 5 hours thereafter.
Inject enough rapid-acting insulin at these times to bring your blood sugars down to your target value. Intramuscular shots are preferred (see here) because of their more rapid effect, but subcutaneous injection is also acceptable. It is prudent to continue blood sugar measurements and insulin coverage, even during the night, for as long as blood sugars continue to rise.
If you’re so ill that you cannot check your own blood sugars and inject your own insulin, someone else must do this for you, or you should be hospitalized. The potential consequences are so serious that you have no other options.
Certain medications that can accelerate dehydration or temporarily impair kidney function should be discontinued during a dehydrating illness. These include diuretics, ACE inhibitors, and certain arthritis medications such as NSAIDs (ibuprofen, Motrin, Advil) and COX-2 inhibitors. NSAIDs may, however, be used as a last resort to treat a fever only if other medications are ineffective. Discuss this with your physician before discontinuing any medication he has prescribed. If you can’t reach him, then discontinue those listed here.
The mainstay of treatment is fluid replacement, but if you’ve been vomiting, you’ll probably be unable to hold anything down, including fluids. If symptoms disappear after vomiting once and you can keep things down, then there’s likely no need for treatment to prevent further vomiting (but still notify your physician). Ordinary vomiting can usually be suppressed with Tigan (trimethobenzamide HCl) injections, administered every 3–5 hours if vomiting persists. Tigan should not be taken by mouth, as it will probably be vomited up before it can work. It is sold in the United States as a 100 mg/ml solution in 20 ml vials. For an adult, we usually inject a trial dose of 30 units with an insulin syringe. It is injected just like insulin. Small children can be started at 10 units. If vomiting persists 30 minutes after injection, the dose can be doubled. Because big injections leave large lumps under the skin, many users prefer to inject multiple 10-unit doses at different sites.
Tigan works for most people, but in about 20 percent of cases, it doesn’t, which is all the more reason to contact your physician when you experience a potentially dehydrating illness. If vomiting or nausea continues for more than 3 hours, or if it cannot be halted by Tigan within 1 hour, he or she may want you to try a second or even a third dose or may prescribe a visit to a hospital emergency room to receive intravenous fluid (saline) and to have the cause established. Some surgical emergencies such as intestinal obstruction can lead to vomiting, as can poisoning, gastroparesis (see Chapter 22), DKA, and so on. Vomiting is a serious problem for people with diabetes, and should not be treated casually.
Large doses of Tigan can cause bizarre neurological side effects,* especially in children and in slim elderly people. The antidote to these effects would be one gulp of diphenhydramine elixir or sugar-free syrup (e.g., Benadryl), if you can hold it down. When vomiting has ceased, Tigan should probably not be administered more often than every 3 hours, or in doses greater than that prescribed by your physician. If Tigan doesn’t work fully within 1 hour, take more and call your physician again.
Once vomiting has been controlled, you should immediately begin to drink fluids. Two questions naturally arise at this point: What fluid? And how much? There are three factors that must be considered in preparing the fluid to be used.
First, it must be something you don’t dislike. Second, it should contain no carbohydrate (therefore no Gatorade, Enfalyte, Oralyte, Glucerna, or sports drinks), but artificial sweeteners are okay. This guideline also contradicts conventional treatment, which usually calls for sweetened beverages to offset the excessive amounts of insulin that many diabetics use. Finally, the fluids should replace the electrolytes—sodium, potassium, and chloride—that are lost from the body when we lose fluids. Beverages commonly used by my patients include diet soda, diluted iced tea, seltzer, water, and carbohydrate-free bouillon or clear soup. To these fluids, we add electrolytes.
Exactly but no more than 1 level teaspoon table salt (½ teaspoon if it tastes too salty) (provides sodium and chloride)
Approximately but no more than ¼ teaspoon salt substitute (see list, here) (provides potassium and chloride)
If the vomiting ceased after one episode without the need for Tigan, it isn’t necessary to add the salts to the fluid you consume.
In anticipation of these rare “sick days,” you should always have on hand several 2-quart bottles of diet soda or seltzer, or two empty 2-quart plastic iced tea pitchers. The pitchers can be used to store whatever rehydration concoction you may prefer instead of diet soda. When the need arises, one pitcher of fluid can be kept by your bedside, while the second is kept cool in the refrigerator.
The volume of fluid you will require each day when not eating depends upon your size, since large people utilize more fluid than small people. If your blood sugars are elevated or if your urine on dipstick is positive for more than moderate amounts of ketones, you will need much more fluid than otherwise. The ongoing fluid requirement for most adults without these problems comes to about 2.7 (women) to 3.7 (men) quarts (or liters) daily while fasting.* In addition, within the first 24 hours you should replace the estimated fluid loss caused by vomiting, fever, or diarrhea. This may come to another few quarts, so clearly you will have to do a lot of drinking. Your physician should be consulted for instructions regarding your fluid intake while ill. Keep an exact record of the volume of fluid consumed, as she may ask for it. If for any reason you cannot consume or keep down the amount of liquid that she or he recommends, you may have to be hospitalized to receive intravenous fluids.
If you do have to be hospitalized for IV fluid replacement, you may run into the difficulty of inexperienced or ignorant hospital personnel wanting to give you one or another standard IV solution that contains some sort of sugar—dextrose, glucose, lactose, lactated Ringer’s solution, fructose, and so on. Do not allow them to do so, and do not assume they know more than you do about your situation. Insist upon a saline solution,* and if they balk, insist upon speaking with the hospital administrator and threaten malpractice and wrongful death lawsuits, if necessary, to persuade them of what you need. Although not usually effective outside the United States, such threats are usually effective here.
First note that any diarrhea with bloody stools or fever requires the immediate attention of a physician or a visit to the emergency room. Here again we are faced with three basic problems: blood sugar control, control of the diarrhea to prevent further water and electrolyte loss, and fluid and electrolyte replacement.
The guidelines for blood sugar control are the same as if you have been vomiting (see above). Fluid and electrolyte replacement should be the same as for vomiting, except that 1 level teaspoon of sodium bicarbonate (baking soda) should be added to each quart of the electrolyte-replacement mixture. The primary treatment for diarrhea, as for vomiting, is to stop eating. Medications to relieve diarrhea, if any, should be specified by your physician. Some forms of diarrhea caused by bacteria, such as “traveler’s diarrhea,” may warrant the use of Pepto-Bismol (bismuth subsalicylate) and antibiotics such as ciprofloxacin or tetracycline.
In my experience, there is one antidiarrheal agent that has always worked, Lomotil (diphenoxylate HCl with atropine sulfate). This is a prescription drug that you should have your doctor prescribe (in advance of any illness) in both liquid form in a dropper bottle and as a tablet. The generic versions are much less expensive and just as effective. You should always have several bottles on hand. You will find dosing instructions on the package insert. If diarrhea continues, double the dose every hour until it ceases and continue the final dose every 3 hours until your physician advises you to discontinue. (Once the diarrhea ceases, it would be more convenient and cheaper for an adult to switch from the liquid to the tablet form of the drug. One 2.5 mg tablet is equivalent to 1 teaspoon or full dropper of the liquid.) Overdosing will not only dry out your gut, which we are seeking, but also can dry out your larynx, mouth, nose, and eyes. Lomotil can also make you drowsy, but its effect on diarrhea is miraculous, in my opinion. If an equivalent to Lomotil is not available in your country, one 30 mg codeine tablet is equivalent to about 10 Lomotil tablets.
If diarrhea is accompanied by fever or bloody stools, do not use Lomotil or codeine, and see a physician immediately. This is because your gut may contain toxic agents that should not be retained.
No doubt you’ve heard the advice “Drink plenty of fluids” for a fever. This is because a fever causes considerable fluid loss through the skin as perspiration. Your loss of fluid can be difficult to estimate, so your physician may want to assume that you’d require 1–2 more quarts of fluid daily than you’d normally need. Ordinarily, a mild fever helps to destroy the infectious agent (virus or bacteria) that is causing the fever. The tendency to sleep out a fever may also be beneficial. For a diabetic, however, the somnolence that you experience with a fever may discourage you from checking your blood sugar, covering with insulin, drinking adequate fluid, and calling your physician every few hours. If you don’t have someone to awaken you every 20 minutes, you should use aspirin, acetaminophen (Tylenol), or ibuprofen (Advil or Motrin), in accordance with your doctor’s instructions, to help fight the fever. Beware, however, that aspirin can cause false positive readings on tests for urinary ketones, so don’t even test for ketones if you are using aspirin. Never use aspirin or ibuprofen (or any of the NSAIDs) for a fever in children because of the risk of Reye’s syndrome. Excessive doses of aspirin or NSAIDs (naproxen, ibuprofen, and many others) can cause severe hypoglycemia. If at all possible, try not to use NSAIDs, as the combination of these drugs with dehydration can cause kidney failure. NSAIDs should never be used by people with kidney impairment. Acetaminophen can be highly toxic if used in doses greater than those indicated on the package label (3,250 mg/day for adults).
If you have a fever, the guidelines for blood sugar control and replacement of fluid are almost the same as indicated previously for vomiting. There is one difference, however. Since there is very little electrolyte loss in perspiration, it’s not necessary to add salts to the fluid you consume if you’re not vomiting or experiencing diarrhea. Certainly there is no reason not to eat if you feel hungry—but if you want to eat, cover your meals with your usual dose of insulin or ISA. If you’re hungry for only a small meal, eat half or a quarter of your usual protein and carbohydrate, and cover it with only half or a quarter of your usual dose of insulin or ISA.
Like hypoglycemia, dehydrating illness can be life-threatening to a diabetic. Encourage the people you live with to read this chapter carefully. The supplies mentioned should be kept in locations known to all. Phone your physician at the first sign of a fever, diarrhea, or vomiting. The chances are that he or she would much rather be contacted early, when dehydration and loss of blood sugar control can be prevented. Emergency situations make treatment more difficult, so you can make your life and your physician’s a bit easier by phoning before major problems occur.
Your physician will probably ask you whether your urine shows ketones, so use the Ketostix whenever you urinate before you call. Also, let your doctor know if you have taken any aspirin in the prior 24 hours, as this can cause a false positive Ketostix reading. If you are not eating, your urine will certainly show “moderate” ketones. Your physician should therefore fear ketoacidosis only if it shows “high” ketones combined with high blood sugars (180 mg/dl or above). Always report your recent blood sugars when you phone your physician.
Most infections can cause elevation of blood sugars, from an infected toe to infected tonsils to infected heart valves. Most infections cause symptoms that are recognizable, such as burning upon urination if you have a urinary tract infection, coughing if you have bronchitis, and so on. So you’ll get pretty prompt warning from your body that you should immediately contact your physician. If you have type 2 diabetes or early type 1, you certainly don’t want your blood sugars to get so high that your remaining beta cells are destroyed. My friend Jay put off visiting a urologist until his blood sugars got so high that his type 2 diabetes became type 1 diabetes and he went from requiring no insulin to 5 daily insulin injections. Occult, or hidden, infections will not become readily apparent unless you notice that your blood sugars have become unreasonably high and you have the good judgment to contact your doctor.
By far the most common type of occult infection is that family of infections that affect dental structures. This includes infections that affect root canals, gums, and jawbones. A history of elevated blood sugars over a period of years predisposes diabetics to such infections; these infections, in turn, predispose diabetics to high blood sugars and severe insulin resistance.
If one of my patients calls our office and complains of recent-onset high blood sugars but no apparent accompanying infection (no coughing, for instance), we ask if she is reusing insulin syringes and contaminating insulin, making injections relatively ineffective (see here). If the answer is no, then we recommend a visit to the dentist immediately to search for an oral infection.
Among the things that your dentist should do are to examine your gums very carefully and to tap every tooth to see if one or more are tender. He or she should also touch each tooth with a chip of ice. Pain upon exposure to cold is the most common overt symptom of infection in the tooth or jawbone, in my experience. We have had patients with dentists who refused to do this and we’ve had to instruct the patients to find better dentists. This is one of those many cases of being a good, educated health care consumer in order to get proper treatment for your diabetes. In each case, when a new dentist performed these tests, a problem was found. If your dentist does find a problem, he or she will probably refer you to an endodontist or periodontist to treat the infection. Not only can dental infections cause blood sugar elevation, but there is now considerable evidence that combinations of dental bacteria in the bloodstream can actually play a role in heart attacks.
Even after such dental infections have been successfully treated, however, blood sugar elevations frequently continue for many months. If blood sugars don’t return to your target immediately after treatment, an appropriate antibiotic should be prescribed and continued until blood sugars remain at their preinfection level. Many people require continuation of antibiotics for as long as a year after treatment to prevent further blood sugar increases. This is because the gum or tooth infection frequently spreads to the adjacent jawbone, causing osteomyelitis. When using oral antibiotics, always take a probiotic every day,* at least 2 hours before or after the antibiotic, to replace gastrointestinal bacteria killed by the antibiotic.
To help prevent dental infections, it is wise to arrange with your dentist for tartar and plaque to be removed from your teeth every three months. The best results are usually achieved by periodontists or their technicians. You should also brush your teeth at least twice daily and after meals floss from between your teeth any food that remains there. If your teeth are too tightly spaced for flossing, try Doctor’s BrushPicks or GUM Soft-Picks, which are available at most pharmacies.
I will personally answer questions from readers for one hour every month. This free service is available by visiting www.askdrbernstein.net.