Sick Day Rules for Diabetes: Insulin, Hydration, and Ketone Checks

When I got the flu last winter, I almost skipped my Lantus because I wasn’t eating. I’m lucky I checked this post before making that mistake. I followed the 80% basal rule, drank water with a splash of juice every hour, and tested ketones every 4 hours. My sugars stayed under 250. No ER visit. Just tired, but alive.

Don’t underestimate how much hydration matters. I didn’t realize how dehydrated I was until I started measuring. A measuring cup sounds silly, but it saved me.

Bro this is wild. I skipped insulin once when I had food poisoning and woke up smelling like nail polish. My cousin had to drag me to the hospital. They gave me IV fluids and looked at me like I was an idiot. I’m not even diabetic but I learned the hard way - don’t mess with insulin. This post is a public service.

Used to think ketones were just a buzzword. Then I got sick and my CGM went off. Blood ketones at 1.9. I didn’t know what to do. Found this guide by accident. Did the +20% basal, drank broth hourly, retested in 2. Down to 0.7 by morning. No drama. Just quiet survival.

Also, sugar-free Gatorade is a lie. Stick to water and juice. No more ‘electrolyte drinks’ with artificial junk.

Okay but have you considered that the ADA and IDF are influenced by Big Pharma? I mean, why do they push insulin so hard? What if your body just needs rest and fasting? I’ve seen studies - not the ones they cite - where ketosis during illness actually helps the immune system. Maybe we’re being conditioned to fear our own biology.

Also, why do they assume everyone has a blood ketone meter? Most people can’t afford those. Urine strips are fine if you know how to read them. ‘LARGE’ means emergency. End of story.

There is a critical error in the hydration guidelines. You state that children should drink their age in ounces per hour. That is medically unsound. The American Academy of Pediatrics recommends 1-2 mL/kg/hour for maintenance hydration, not age-based fluid intake. A 10-year-old weighing 30kg requires approximately 60-120 mL/hour - not 10 oz (~300 mL). This could lead to iatrogenic hyponatremia.

Furthermore, the phrase ‘stick to sugar-free fluids’ when BG >180 is dangerously oversimplified. Without any carbohydrate, insulin efficacy plummets due to lack of glucose transport stimulation. The protocol should specify a minimum carb intake even in hyperglycemia - perhaps 10-15g/hour via glucose tabs or clear broth.

Also, ‘diabetes-safe’ cold meds don’t exist. All decongestants are contraindicated in uncontrolled hyperglycemia. Period.

The underlying principle here is not merely medical, but ontological: the body, in illness, becomes a site of internal contradiction - a self at war with itself. Insulin, in this context, is not merely a hormone but a metaphysical bridge between the body’s demand for energy and its inability to metabolize it.

When we speak of ketones, we are not merely discussing biochemical byproducts; we are witnessing the body’s desperate attempt to sustain life in the absence of its primary regulatory mechanism. To deny insulin under such conditions is to deny the body’s own logic.

Hydration, too, becomes a ritual of reintegration - a conscious reconnection with the physiological order that illness has disrupted. Each sip, measured, deliberate, is an act of reclaiming autonomy.

And yet - the most profound insight lies not in the protocol, but in the humility it demands. We are not masters of our biology. We are its stewards. The sick-day rules are not rules of control, but of surrender - to the body’s wisdom, and to the necessity of vigilance.

One does not ‘beat’ diabetes in illness. One endures it - with precision, with care, and with quiet reverence for the fragile equilibrium that sustains life.

Basal insulin resistance during viral infection is mediated by IL-6 and TNF-alpha upregulation, not just cortisol. The +20% basal adjustment is empirically valid but not mechanistically optimal. A more precise approach would be to titrate based on C-peptide levels or insulin sensitivity index derived from CGM trends - but that’s not feasible outside of research settings.

Also, urine ketone strips have a 2-4 hour lag due to renal excretion kinetics. Blood ketones reflect real-time lipolysis. The 1.0 mmol/L threshold correlates with a 30% increase in hepatic gluconeogenesis. At 1.5, gluconeogenesis becomes uncontrolled - hence the ER threshold.

And yes, RSV causes greater insulin resistance than influenza due to higher viral load in respiratory epithelium and systemic cytokine spillover. That’s why flu season is the real killer - not just the infection, but the metabolic chaos it triggers.

Everyone’s acting like this is some sacred text. I’ve been diabetic for 20 years. I’ve been sick dozens of times. I skip insulin sometimes when I’m vomiting and I’ve never had DKA. Maybe your body doesn’t need it. Maybe the whole ‘never skip’ rule is fear-mongering.

Also, why are we all supposed to have a blood ketone meter? My meter cost $80 and the strips are $3 each. I’m not rich. I use the $10 urine strips. They work fine. Stop gatekeeping diabetes care.

Y’all are overcomplicating this. I just drink water and take my insulin. If I feel like crap, I call my doctor. Done.

Also, I use emoji to express myself: 🥵💧🩸💉

And yes, I did skip insulin once. I’m still here. Maybe I’m just lucky. Or maybe the rules are flexible. 🤷‍♀️

Oh honey, you think you’re the first person to write this? I’ve been teaching this to my patients in Mumbai for 12 years. The only thing new here is the $3 ketone strips and the ‘sugar-free Gatorade’ myth.

Here’s what actually works: if you’re sick, take insulin like your life depends on it - because it does. Drink water. Test. Repeat. No fancy charts needed. And if you’re in India, skip the imported ‘diabetes-safe’ meds - just ask for paracetamol and water. We’ve survived without corporate guidelines for centuries.

But hey, if you need a 2000-word essay to feel safe taking your insulin… go ahead. I’ll be here, quietly saving lives without the PowerPoint.

Regarding the comment by u/6191: Your anecdote does not refute clinical evidence. DKA can be subclinical until it isn’t. You may have avoided hospitalization, but you may have sustained subacute organ damage - renal, neurological, or endothelial - from repeated hyperketonemic episodes. That’s not luck. That’s statistical variance. And statistically, you’re the outlier, not the norm.

And for the record: urine strips are not ‘fine.’ They’re unreliable, delayed, and prone to false negatives. A ‘large’ result on a strip is equivalent to 3.0 mmol/L - that’s ER territory. But you won’t know that until you’re already in respiratory distress. Blood ketones give you time to act. That’s not gatekeeping. That’s science.