Patient discussions

Management should be reviewed periodically with all patients. This should include:

  • When to contact the healthcare provider

  • Blood glucose goals and the use of supplemental short- or rapid-acting insulin during illness

  • Means to suppress fever and treat infection

  • Initiation of an easily digestible fluid diet containing electrolytes and glucose during illness.

Patients should be advised to always continue insulin during illness and to seek professional advice early. Sodium-glucose co-transporter 2 (SGLT2) inhibitor-associated DKA in patients with type 2 diabetes is typically precipitated by insulin omission or significant dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. DKA prevention strategies should include withholding SGLT2 inhibitors when precipitants are present, and avoiding insulin omission or large insulin dose reduction.[44][45]

The patient (or family member or carer) must be able to accurately measure and record blood glucose, insulin administration, temperature, respiratory rate, and pulse. Blood ketone (BOHB) should be checked when blood glucose is more than 16.7 mmol/L (300 mg/dL), and if it is high the patient should present to hospital for further evaluation. The frequency of blood glucose monitoring depends on the patient's clinical condition: in uncontrolled diabetes (HbA1c >53 mmol/mol [>7.0%]) it is recommended to check blood glucose before each meal, plus at bedtime.[1][141] In the UK, all patients with type 1 diabetes mellitus should be offered real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM, or ‘flash’ glucose monitoring).[43]

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