What are the recommended sick‑day management guidelines for a patient with diabetes, including medication adjustments, glucose and ketone monitoring, and hydration?

Sick Day Rules for Diabetes Patients

When a diabetes patient develops acute illness with vomiting, diarrhea, or significantly reduced fluid intake, they should temporarily stop SGLT2 inhibitors, metformin, ACE inhibitors/ARBs, diuretics, and NSAIDs for up to 72 hours while increasing fluid intake and monitoring blood glucose every 4-6 hours. 1

When to Initiate Sick Day Rules

Trigger sick day management when the patient experiences any of the following NEW or WORSENED symptoms indicating volume depletion 1:

• Vomiting or diarrhea causing significant fluid losses (100% consensus)
• Nausea or anorexia reducing fluid intake substantially (88% consensus)
• Lightheadedness, dizziness, or orthostatic symptoms (88% consensus)
• Weight loss of 3 kg in 2 days (83% consensus)
• Decreased urine output (75% consensus)

Medication Adjustments

Medications to STOP Temporarily (for up to 3 days or until symptoms resolve) 1:

High priority to stop:

• SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) - 96% consensus
• Metformin - 86% consensus
• ACE inhibitors/ARBs (perindopril, candesartan, lisinopril, losartan) - 90% consensus
• All diuretics:
  • Loop diuretics (furosemide) - 95% consensus
  • Thiazide/thiazide-like (HCTZ, indapamide) - 90% consensus
  • Potassium-sparing (spironolactone, amiloride) - 95% consensus
• NSAIDs - 95% consensus
• ARNI (sacubitril/valsartan) - 88% consensus

Critical nuance: The 2023 consensus guidelines show strong agreement (86-96%) for stopping these medications because they increase risk of acute kidney injury and metabolic complications during volume depletion 1, 2.

Medications Requiring Glucose-Based Adjustment (DO NOT automatically stop) 1:

Insulin:

• If glucose is LOW: Hold insulin until glucose recovers (96% consensus)
• If glucose is ELEVATED: Increase basal and bolus insulin by 10-20% empirically; if unsuccessful after 24 hours, contact healthcare provider (87% consensus)
• Never completely stop insulin in type 1 diabetes - this is a critical pitfall that can precipitate DKA

Sulfonylureas/Meglitinides:

• If glucose is LOW: Hold until glucose recovers (96% consensus)
• If already taken: Eat foods to prevent hypoglycemia for 12-24 hours until medication effect wears off (78% consensus)

GLP-1 receptor agonists: Did NOT reach consensus for routine stopping (only 57% agreement) - continue unless specific contraindications 1

Monitoring Requirements

Blood Glucose Monitoring 1:

• Patients on insulin: Check every 4-6 hours while awake for duration of symptoms (100% consensus)
• This is MORE frequent than usual monitoring

Ketone Monitoring 1:

• Check ketones if patient takes:
  • SGLT2 inhibitors (95% consensus)
  • Insulin (95% consensus)
  • Following ketogenic diet (95% consensus)
• Use blood ketone meters when available (more accurate than urine) 3

Hydration 1:

• Increase fluid intake with limited caffeine (92% consensus)
• Consider electrolyte replacement solutions (92% consensus)
• This is essential to reverse volume depletion and prevent acute kidney injury 2

When to Contact Healthcare Provider

Seek assistance from healthcare provider when: 1

• Patient feels unable to cope (100% consensus)
• Symptoms persist beyond 72 hours (100% consensus)
• Cannot keep down foods or fluids (100% consensus)
• Recurrent low blood glucose readings (96% consensus)
• Blood glucose remains significantly elevated despite self-adjustment after 24 hours (96% consensus)
• Moderate or high ketones detected (91% consensus)
• Vomiting >4 times in 12 hours (96% consensus)
• Blood pressure drops (SBP <80 mmHg or drop of 20 mmHg systolic/10 mmHg diastolic) - 92% consensus
• Heart rate increases by 30 bpm (79% consensus)
• Fever >38°C (101°F) on 2 measurements (75% consensus)

When to Call 911/Seek Emergency Care

Immediately seek emergency care for: 1

• Difficulty or rapid breathing (100% consensus)
• Reduced consciousness or new confusion (96% consensus)
• Fainting or falls (71% consensus)

These symptoms suggest impending DKA, severe dehydration, or other life-threatening complications 4, 5.

Resuming Medications

Timeline for restarting medications after symptoms resolve: 1

• Medications causing hypoglycemia (insulin, sulfonylureas): Resume at usual doses as soon as symptoms improve AND normal eating/drinking resumes (100% consensus)
• Volume-depleting medications (diuretics, ACE inhibitors/ARBs): Resume at usual doses within 24-48 hours of eating and drinking normally (95% consensus)
• All other temporarily stopped medications: Resume at usual doses within 24-48 hours of eating and drinking normally (95% consensus)
• If symptoms last >72 hours: Contact healthcare provider before resuming any medications (100% consensus)

Critical Pitfalls to Avoid

1. Never completely stop insulin in type 1 diabetes - adjust based on glucose levels but maintain basal coverage to prevent DKA 4, 5
2. Do not wait too long to check ketones - particularly important for SGLT2 inhibitor users who can develop euglycemic DKA 6
3. Self-management is only appropriate for maximum 72 hours - beyond this, medical supervision is required 1
4. Do not assume GLP-1 agonists need to be stopped - evidence did not support routine discontinuation 1
5. Patients on sulfonylureas who already took their dose need carbohydrate intake to prevent delayed hypoglycemia over 12-24 hours 1

This guidance represents the 2023 international consensus from a modified Delphi process specifically designed to prevent medication-related complications during acute illness in diabetes patients 1, 2.