During acute illness with fever, vomiting, diarrhea, or reduced oral intake, which medications should be stopped?

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Last updated: October 18, 2026 • View editorial policy

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Which Medications to Stop During Sick Days

During acute illness with vomiting, diarrhea, fever, or reduced oral intake, temporarily stop SGLT2 inhibitors, ACE inhibitors/ARBs, diuretics (all types), NSAIDs, metformin, and ARNI medications for up to 3 days or until symptoms resolve. 1

Medications That Should Be Stopped

Based on international consensus guidelines, the following medications require temporary discontinuation during acute dehydrating illness 1:

Stop Immediately (High Priority):

  • SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) - 96% consensus 1
  • NSAIDs (ibuprofen, naproxen, diclofenac) - 95% consensus 1
  • All diuretics:
    • Loop diuretics (furosemide) - 95% consensus 1
    • Thiazide/thiazide-like diuretics (hydrochlorothiazide, indapamide) - 90% consensus 1
    • Potassium-sparing diuretics (spironolactone, amiloride) - 95% consensus 1
  • ACE inhibitors/ARBs (perindopril, candesartan, lisinopril, losartan) - 90% consensus 1
  • ARNI (sacubitril/valsartan) - 88% consensus 1
  • Metformin - 86% consensus 1
  • Direct renin inhibitors (aliskiren) - 82% consensus 1

Conditional Management (Blood Glucose-Dependent):

Do NOT automatically stop these medications - adjust based on blood glucose levels 1:

  • If blood glucose is LOW: Hold insulin, sulfonylureas (glipizide, glyburide), and meglitinides until glucose recovers - 96% consensus 1
  • If blood glucose is ELEVATED: Increase basal and bolus insulin by 10-20% empirically 1

Medications to CONTINUE:

  • GLP-1 receptor agonists (liraglutide, semaglutide) - panel did NOT reach consensus to stop these due to long half-lives and lack of expected worsening of volume depletion 1
  • Sedative medications - do NOT stop due to risk of withdrawal 1

When to Initiate Sick Day Rules

Trigger sick day medication guidance when experiencing 1:

  • Vomiting or diarrhea with significant fluid losses (100% consensus)
  • Anorexia or nausea causing decreased fluid intake (88% consensus)
  • New lightheadedness, dizziness, or orthostatic symptoms (88% consensus)
  • Weight loss >3 kg in 2 days (83% consensus)
  • Decreased urine output (75% consensus)

Duration and Resumption

Stop medications for:

  • Up to 3 days maximum (100% consensus) 1
  • Until signs and symptoms resolve (88% consensus) 1

Resume medications:

  • Within 24-48 hours of eating and drinking normally (95% consensus) 1
  • For medications causing hypoglycemia (insulin, sulfonylureas), resume at usual doses as soon as normal eating resumes (100% consensus) 1
  • For volume-depleting medications, resume at usual doses within 24-48 hours of normal oral intake (95% consensus) 1

Critical Warning Signs Requiring Immediate Medical Contact

Seek healthcare provider assistance when 1:

  • Reduced consciousness or new confusion (100% consensus)
  • Vomiting >4 times in 12 hours or cannot keep fluids down (96% consensus)
  • Systolic BP <80 mmHg or drop of 20 mmHg (92% consensus)
  • Moderate or high ketones (91% consensus for SGLT2i or insulin users)
  • Heart rate increase by 30 bpm (79% consensus)
  • Fever >38°C on 2 measurements (75% consensus)
  • Symptoms not resolved within 72 hours (100% consensus)

Rationale and Pathophysiology

The mechanism behind sick day rules centers on preventing acute kidney injury during volume depletion 2, 3. When dehydration occurs, medications that affect renal perfusion (ACE inhibitors/ARBs, diuretics), increase renal stress (NSAIDs, metformin), or promote fluid loss (SGLT2 inhibitors) create a dangerous cascade that can lead to acute renal failure and toxic drug accumulation 3. This creates a potentially fatal vicious circle where kidney injury worsens drug toxicity, which further damages the kidneys.

Important Caveats

Self-management is only appropriate when 1:

  • Absence of severe symptoms (96% consensus)
  • Patient feels able to cope (92% consensus)
  • Patient can maintain fluid intake (88% consensus)

Additional monitoring requirements during sick days 1:

  • Patients on insulin: check blood glucose every 4-6 hours while awake (100% consensus)
  • Patients on SGLT2 inhibitors or insulin: check urine ketones (95% consensus)
  • Increase fluid intake with electrolyte replacement solutions (92% consensus)

The consensus panel specifically excluded GLP-1 receptor agonists from the stop list despite some resources recommending this, recognizing their long half-lives make temporary discontinuation impractical and they don't significantly worsen volume depletion 1.

References

2
Research

Choosing wisely in practice: How sick day rules help prevent medication-related complications.

Ceska a Slovenska farmacie : casopis Ceske farmaceuticke spolecnosti a Slovenske farmaceuticke spolecnosti, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.