Sick Day Plan for Type 2 Diabetes
Patients with type 2 diabetes experiencing acute illness with signs of volume depletion must temporarily stop specific medications (SGLT2 inhibitors, metformin, ACE inhibitors/ARBs, diuretics, NSAIDs), increase glucose monitoring frequency, maintain hydration, and adjust insulin doses based on blood glucose levels. 1
When to Activate Sick Day Management
Initiate sick day protocols when experiencing any of these signs of volume depletion: 1
- Diarrhea (≥3 loose stools in 24 hours)
- Vomiting (≥2 episodes in 24 hours)
- Reduced oral intake
- Fever
- Excessive sweating
Medications to STOP Temporarily
Immediately discontinue these medications for up to 3 days or until symptoms resolve: 1
- SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) 1
- Metformin 1
- ACE inhibitors/ARBs (including sacubitril/valsartan) 1
- All diuretics (loop, thiazides, potassium-sparing) 1
- NSAIDs 1
Critical caveat: SGLT2 inhibitors carry particular risk for diabetic ketoacidosis during illness, even with normal or mildly elevated glucose levels. 1
Insulin and Hypoglycemic Agent Adjustments
If Blood Glucose is LOW (below target):
- Hold insulin, sulfonylureas, and meglitinides until blood glucose recovers 1
- Resume at usual doses once eating and drinking normally 1
If Blood Glucose is ELEVATED (above usual levels):
- Increase basal and bolus insulin by 10-20% empirically 1
- If unsuccessful at lowering glucose, contact healthcare provider 1
- Never discontinue insulin entirely, even if unable to eat 1, 2
Key principle: Insulin requirements often increase during illness despite reduced food intake due to stress hormones and counter-regulatory responses. 1, 2
Self-Monitoring Requirements
Increase monitoring frequency during illness: 1, 3
- Check blood glucose every 2-4 hours 1
- Check blood or urine ketones when glucose >300 mg/dL 1, 3
- Record temperature, pulse, respiratory rate 1
- Monitor for ketones even with normal glucose if on SGLT2 inhibitors 1
Hydration and Nutrition Strategy
Maintain fluid and carbohydrate intake: 1, 3
- Drink 8 oz of fluid every hour while awake 1
- Consume easily digestible liquids containing both carbohydrates and salt 1
- Eat small amounts of food to prevent hypoglycemia, even if nauseous 1, 3
- Continue drinking even if vomiting 1
When to Contact Healthcare Provider URGENTLY
Seek immediate medical attention for: 1
- Reduced level of consciousness or confusion
- Severe vomiting (unable to keep fluids down)
- Blood pressure <90/60 mmHg or symptomatic hypotension
- Presence of moderate-to-large ketones
- Heart rate >100 bpm at rest
- Fever >101°F (38.3°C) that persists
- Symptoms lasting >72 hours 1
- Major changes in blood glucose levels despite adjustments 1
Resuming Medications
Restart medications systematically once recovered: 1
- Medications causing hypoglycemia: Resume at usual doses as soon as symptoms improve and normal eating resumes 1
- Volume-depleting medications: Resume at usual doses within 24-48 hours of eating and drinking normally 1
- All other held medications: Resume within 24-48 hours of symptom resolution 1
Do not wait for complete recovery—restart within 48 hours if eating and drinking adequately. 1
Essential Patient Education Components
All patients must understand: 1, 3
- Which specific medications to stop and which to continue 1, 3
- How to recognize and treat hypoglycemia 1, 3
- Proper glucose and ketone monitoring technique 1
- When to contact healthcare provider 1, 3
- Never discontinue insulin for economic or other reasons 1
- Insulin storage and injection technique 1
Common pitfall: Patients often discontinue all diabetes medications during illness, which can precipitate diabetic ketoacidosis, particularly in those with diminishing insulin secretory capacity. 1 The distinction between medications to stop (SGLT2i, metformin, RAS inhibitors) versus those to adjust (insulin) or continue is critical for preventing both acute kidney injury and hyperglycemic crises. 1