Management of Diabetic Patients with Vomiting and Diarrhea
For diabetic patients with vomiting and diarrhea, immediate fluid replacement with oral rehydration solution is the first-line treatment, while temporarily holding certain medications including SGLT2 inhibitors, ACE inhibitors/ARBs, NSAIDs, diuretics, and adjusting insulin doses based on frequent blood glucose monitoring. 1
Initial Assessment
Assess severity of dehydration:
Check blood glucose levels every 4-6 hours while awake and for the duration of symptoms 1
Monitor for ketones if patient is on SGLT2 inhibitors or insulin 1
Evaluate electrolytes if possible, as hypokalaemia is common in acute gastroenteritis 2
Fluid Replacement Therapy
For Mild to Moderate Dehydration:
- Oral rehydration solution (ORS) is the first-line therapy 1
- Adults should consume 2-4 L of ORS, with additional 120-240 mL after each diarrheal stool or vomiting episode 1
- Commercial formulations include Pedialyte, CeraLyte, and Enfalac Lytren 1
- Avoid apple juice, Gatorade, and commercial soft drinks as they are not suitable for rehydration 1
For Severe Dehydration:
- Intravenous isotonic fluids (lactated Ringer's or normal saline) should be administered 1
- Continue IV rehydration until pulse, perfusion, and mental status normalize 1
- If patient has ketonemia, initial IV hydration may be needed before transitioning to oral rehydration 1
Medication Management During Illness
Medications to Temporarily Hold:
- SGLT2 inhibitors (e.g., empagliflozin) 1
- ACE inhibitors/ARBs (e.g., perindopril, candesartan) 1
- NSAIDs 1
- All diuretics:
Diabetes Medication Adjustments:
- If blood glucose is low, hold insulin/sulfonylurea/meglitinide until blood glucose recovers 1
- Patients who took their daily dose of sulfonylurea should eat foods to prevent hypoglycemia until medication effect wears off (12-24 hours) 1
- For patients on insulin: continue insulin but adjust doses based on frequent monitoring 1
- Never completely discontinue insulin in type 1 diabetes, as this can lead to diabetic ketoacidosis 1
Symptomatic Treatment
For Nausea and Vomiting:
- For diabetic gastroparesis, consider metoclopramide to relieve symptoms 3
- Caution: Metoclopramide should be used at the lowest effective dose in elderly patients due to risk of extrapyramidal side effects 4
For Diarrhea:
- Loperamide is recommended as first-line therapy: initial dose 4 mg followed by 2 mg after each loose stool (not exceeding 16 mg/day) 5
- Continue loperamide until diarrhea-free for at least 12 hours 5
Dietary Recommendations
- Recommend a bland diet (BRAT: Bananas, Rice, Applesauce, Toast) while symptoms persist 5
- Gradually add solid foods to diet as symptoms improve 1
- Avoid lactose-containing products and high-osmolar dietary supplements 1
When to Seek Medical Attention
Advise patients to seek immediate medical care if:
- Symptoms have not resolved within 72 hours 1
- Unable to keep fluids down 1
- Recurrent low blood glucose readings 1
- Significant increase in blood glucose not improving with self-adjustment after 24 hours 1
- Moderate or high ketones (for patients taking SGLT2i or insulin) 1
- Reduced level of consciousness or new confusion 1
Prevention of Hyperglycemic Crises
Sick-day management should include specific instructions on:
- When to contact healthcare provider
- Blood glucose goals and use of supplemental short-acting insulin during illness
- Means to suppress fever and treat infection
- Initiation of easily digestible liquid diet containing carbohydrates and salt 1
Most importantly, never discontinue insulin completely in type 1 diabetes 1
Pitfalls to Avoid
- Do not use popular beverages like apple juice or sports drinks for rehydration 1
- Avoid anticholinergic, antidiarrheal, and opioid agents in patients with suspected ileus 1
- Do not correct electrolyte abnormalities too rapidly, especially sodium 6
- Remember that hyperglycemia itself can worsen gastric emptying, creating a vicious cycle 1