Sick Day Management Guidelines for Patients with Diabetes Mellitus
During illness, patients with diabetes should never discontinue insulin, should monitor blood glucose every 2-4 hours, check for ketones when blood glucose is elevated, and temporarily stop certain medications like SGLT2 inhibitors, metformin, and ACE inhibitors for up to 3 days or until symptoms resolve. 1, 2
Triggers for Implementing Sick Day Management
Sick day management should be initiated when patients experience:
- Vomiting or diarrhea resulting in significant fluid losses (100% consensus) 1
- Anorexia or nausea resulting in significant decrease in fluid intake (88% consensus) 1
- New lightheadedness, dizziness, or fainting (88% consensus) 1
- Decreased weight (3 kg in 2 days) (83% consensus) 1
- Decreased urine output (75% consensus) 1
Monitoring Recommendations
- Blood glucose monitoring: Check every 2-4 hours while awake 1, 2
- Ketone monitoring: Required for patients on SGLT2 inhibitors, insulin, or ketogenic diets 1
- Additional monitoring: Track temperature, respiratory rate, pulse, body weight, fluid intake, and output 2
Medication Management During Illness
Medications to Temporarily Stop (for up to 3 days or until symptoms resolve):
- SGLT2 inhibitors (96% consensus) - Risk of dehydration and diabetic ketoacidosis 1
- Metformin (86% consensus) - Risk of lactic acidosis with dehydration 1
- ACE inhibitors/ARBs (90% consensus) - Risk of acute kidney injury 1
- Diuretics (loop, thiazide, potassium-sparing) (90-95% consensus) - Risk of dehydration 1
- NSAIDs (95% consensus) - Risk of kidney injury 1
Medications to Continue with Adjustments:
Sulfonylureas: If taken, try to eat to prevent hypoglycemia until medication effect wears off (12-24h) 1
DPP-4 inhibitors: Generally well tolerated and can be continued 1
GLP-1 receptor agonists: Consider holding if significant dehydration (57% consensus) 1
Hydration and Nutrition
- Increase fluid intake with limited caffeine; consider electrolyte replacement solutions (92% consensus) 1
- If unable to eat solid food, substitute with liquid carbohydrates (broth, juice) 2
- For elevated blood glucose, use sugar-free fluids 2
When to Seek Medical Assistance
Contact healthcare provider immediately when:
- Symptoms have not resolved within 72 hours (100% consensus) 1
- Patient feels they are not coping (100% consensus) 1
- Unable to keep up with intake of foods or fluids (100% consensus) 1
- Recurrent low blood glucose readings (96% consensus) 1
- Significant increase in blood glucose not responding to self-adjustment after 24 hours (96% consensus) 1
Seek emergency care for:
- Difficulty or rapid breathing (100% consensus) 1
- Reduced level of consciousness or new confusion (96% consensus) 1
- Vomiting >4 times in 12 hours or inability to keep fluids down (96% consensus) 1
- Low blood pressure (SBP <80 mm Hg or drop of 20 mm Hg) (92% consensus) 1
- Moderate or high ketones (for patients on SGLT2i or insulin) (91% consensus) 1
Common Pitfalls to Avoid
- Discontinuing insulin completely: Most dangerous mistake that can lead to DKA or HHS 2
- Inadequate monitoring: Failing to check glucose and ketones frequently 2
- Insufficient fluid intake: Worsens dehydration and hyperglycemia 2
- Delayed medical attention: Not seeking help when symptoms persist or worsen 2
- Leaving sick day management to children or teenagers alone: Adult supervision is essential 1
Special Considerations for Type 1 Diabetes
- Risk of DKA is higher during illness, particularly for those on SGLT2 inhibitors 1
- Parental involvement and telephone availability of diabetes clinician are essential for children and adolescents 1
- Effects of illness on insulin requirements are variable - stress hormones may increase needs while decreased food intake may decrease needs 1
By following these guidelines, patients with diabetes can effectively manage their condition during illness, reducing the risk of serious complications like DKA, HHS, and dehydration.