Sick Day Medication Guidance (SDMG) According to KDIGO
"Sick day rest" is not a KDIGO-specific term, but KDIGO emphasizes sick day medication guidance (SDMG), which involves temporarily stopping certain medications during acute illness with volume depletion to prevent acute kidney injury (AKI), hypotension, and hypoglycemia 1, 2.
What Triggers Sick Day Medication Guidance
SDMG should be initiated when patients experience signs and symptoms of volume depletion during acute illness 1. The consensus recommendations identify 5 specific triggers related to volume depletion, though the evidence doesn't detail all of them explicitly.
Medications to STOP Temporarily
The following medications must be temporarily discontinued during sick days 1:
- Renin-angiotensin system inhibitors (ACE inhibitors, ARBs)
- Diuretics (all types)
- NSAIDs (nonsteroidal anti-inflammatory drugs)
- SGLT2 inhibitors (sodium/glucose cotransporter 2 inhibitors)
- Metformin
Medications to ADJUST (Not Automatically Stop)
Diabetes medications require conditional management 1:
- Insulin, sulfonylureas, and meglitinides: Hold ONLY if blood glucose is low
- If blood glucose is elevated: Increase basal and bolus insulin by 10-20%
When to Seek Urgent Medical Care
Patients should contact a healthcare provider immediately if they experience 1:
- Reduced level of consciousness
- Severe vomiting
- Low blood pressure
- Presence of ketones
- Tachycardia
- Fever
Patient Self-Management Strategies
During sick days, patients should 1:
- Monitor blood glucose frequently
- Check for ketones
- Maintain adequate fluid intake
- Consume food to prevent hypoglycemia
When to Resume Medications
Restart medications within 24-48 hours after 1:
- Resolution of acute illness symptoms
- Return to normal eating and drinking patterns
Important Clinical Context
The 2024 KDIGO guidelines emphasize nephrotoxin stewardship and AKI prevention through patient education on sick day medication management 2. This represents a shift toward proactive prevention rather than reactive treatment. Pharmacists play a crucial role in implementing these recommendations through patient education and medication management 2.
Implementation Challenges
Research reveals that while clinicians initially express enthusiasm for sick day guidance, implementation faces barriers including 3, 4:
- Complexity in patients with multiple conditions (especially chronic heart failure)
- Difficulty communicating temporary medication cessation
- Need for adequate resourcing and training
- Tension between broad reach and ensuring patient understanding
The sick day guidance works best when integrated into comprehensive care rather than as a standalone intervention 4. Patients with limited capacity for self-management require particular attention and may need more intensive support.