Immediate Management: Stop High-Risk Medications and Assess Severity
Your relative needs to temporarily stop her ACE inhibitor/ARB, diuretics, and SGLT2 inhibitor (if taking one) immediately due to vomiting and diarrhea, and she should contact her healthcare provider today given her high-risk conditions. 1
Critical Assessment Needed Now
Given that she has both PAH and diabetes with active vomiting and diarrhea, you need to determine severity:
Seek Emergency Care (911) If:
- Reduced consciousness or new confusion
- Difficulty or rapid breathing
- Fainting or falls
- Cannot keep any fluids down 1
Contact Healthcare Provider Today If:
- Vomiting >4 times in 12 hours
- Cannot keep fluids down
- Lightheadedness or dizziness when standing
- Blood pressure drops significantly (>20 mmHg systolic drop)
- Blood glucose repeatedly low or persistently high despite adjustments 1
This is particularly urgent because PAH patients do not tolerate fluid shifts well, and volume depletion can precipitate right ventricular failure—a life-threatening complication. 2, 3
Medication Management (Sick Day Rules)
Stop Immediately:
- ACE inhibitors/ARBs (e.g., lisinopril, losartan)
- All diuretics (furosemide, hydrochlorothiazide, spironolactone)
- SGLT2 inhibitors if prescribed (empagliflozin, dapagliflozin)
- NSAIDs if taking any 1
Diabetes Medications - Special Handling:
- If taking sulfonylureas (glipizide, glyburide): Try to eat something to prevent low blood sugar, as these medications continue working for 12-24 hours
- If taking insulin: Check blood glucose every 4-6 hours while awake; hold dose if blood glucose is low
- Check ketones if taking SGLT2 inhibitors or insulin—moderate or high ketones require immediate medical attention 1
Continue:
- PAH-specific medications (sildenafil, tadalafil, bosentan, ambrisentan, etc.) - these should NOT be stopped 4
- Other cardiac medications unless specifically instructed otherwise
Self-Management Actions (If No Severe Symptoms)
Self-management is only appropriate if she:
- Can keep fluids down
- Feels able to cope
- Has no severe warning signs 1
Fluid Replacement:
- Increase fluid intake with electrolyte replacement solutions (Pedialyte, sports drinks)
- Limit caffeine
- Small, frequent sips if nausea present 1
Monitoring:
- Check blood glucose every 4-6 hours if on insulin
- Monitor for ketones if on SGLT2 inhibitors or insulin
- Watch for decreased urine output, increased weakness, or worsening symptoms 1
Critical Time Limits
Contact healthcare provider if:
- Symptoms persist beyond 72 hours
- She cannot maintain fluid intake
- She feels she's not coping
- Blood glucose remains significantly elevated after 24 hours despite adjustments 1
Why This Matters for PAH Patients
PAH patients are at exceptionally high risk during acute illness because:
- Volume depletion can precipitate right ventricular failure, which is the primary cause of death in PAH 2, 3
- They cannot compensate for fluid shifts like other patients
- Electrolyte abnormalities (especially from vomiting/diarrhea) can trigger dangerous arrhythmias
- Hospitalization in PAH carries high mortality risk, making prevention of decompensation critical 3
Common Pitfall to Avoid
Do not continue diuretics or ACE inhibitors/ARBs during acute gastroenteritis thinking they're "too important to stop"—the consensus guidelines are clear that temporary discontinuation during volume-depleting illness is essential to prevent acute kidney injury and cardiovascular collapse. 1 These can be safely restarted once she's eating and drinking normally again.