What is the recommended sick day medication regimen for patients with diabetes?

Sick Day Medication Management for Patients with Diabetes

Patients with diabetes experiencing acute illness with signs of volume depletion must immediately stop SGLT2 inhibitors, metformin, ACE inhibitors/ARBs, diuretics, and NSAIDs for up to 3 days or until symptoms resolve, while increasing glucose monitoring to every 4-6 hours and maintaining aggressive hydration. 1, 2

Medications to Temporarily Stop During Illness

High Priority - Stop Immediately:

• SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) - 96% consensus recommendation due to diabetic ketoacidosis risk even with normal glucose levels 1, 2
• Metformin - 86% consensus to stop due to lactic acidosis risk during volume depletion 1, 2
• ACE inhibitors/ARBs - 90% consensus to withhold due to acute kidney injury risk 1, 2
• All diuretics (loop, thiazide, potassium-sparing) - 90-95% consensus to stop 1, 2
• NSAIDs - 95% consensus to discontinue 1, 2
• ARNI (sacubitril/valsartan) - 88% consensus to hold 1

Duration of Medication Hold:

• Stop for up to 3 days or until signs and symptoms have resolved (100% and 88% consensus respectively) 1, 2
• Resume volume-depleting medications at usual doses within 24-48 hours of eating and drinking normally 1, 2

Insulin and Hypoglycemic Agent Adjustments

If Blood Glucose is LOW:

• Hold insulin, sulfonylureas, and meglitinides until blood glucose recovers (96% consensus) 1, 2
• If sulfonylurea was already taken, consume foods to prevent hypoglycemia for 12-24 hours until medication effect wears off (78% consensus) 1
• Resume at usual doses as soon as symptoms improve and normal eating resumes (100% consensus) 1, 2

If Blood Glucose is ELEVATED:

• Increase basal and bolus insulin by 10-20% empirically 1, 2
• If unsuccessful at lowering blood glucose after this adjustment, contact healthcare provider 1, 2

Critical Pitfall: Never discontinue basal insulin completely in patients with type 1 diabetes, even during illness, as this can precipitate diabetic ketoacidosis 1

Monitoring Requirements During Illness

Glucose Monitoring:

• Increase frequency to every 4-6 hours while awake for all patients on insulin (100% consensus) 1
• Check every 2-4 hours during acute illness 2

Ketone Monitoring:

• Patients on SGLT2 inhibitors, insulin, or ketogenic diets should check ketones (95% consensus) 1
• Check blood or urine ketones when glucose >300 mg/dL 2
• SGLT2 inhibitors carry particular risk for euglycemic ketoacidosis (normal or mildly elevated glucose with ketones) 2

Hydration and Nutrition Management

• Drink 8 oz of fluid every hour while awake 2
• Use limited caffeine and consider electrolyte replacement solutions (92% consensus) 1
• Consume easily digestible liquids containing both carbohydrates and salt 2
• Maintain fluid and carbohydrate intake even if unable to eat solid foods 2

When to Seek Immediate Medical Attention

Contact healthcare provider or seek emergency care for:

• Difficulty or rapid breathing (100% consensus) 1, 2
• Reduced level of consciousness or new confusion (96% consensus) 1, 2
• Blood pressure <90/60 mmHg or symptomatic hypotension 2
• Moderate-to-large ketones present 2
• Heart rate >100 bpm at rest 2
• Fever >101°F (38.3°C) that persists 2
• Symptoms lasting >72 hours (100% consensus) 1, 2
• Recurrent low blood glucose readings (96% consensus) 1
• Significant increase in blood glucose not responding to self-adjustment after 24 hours (96% consensus) 1
• Fainting or falls (71% consensus) 1

Resuming Medications After Illness Recovery

Systematic Restart Protocol:

1. Medications causing hypoglycemia (insulin, sulfonylureas, meglitinides): Resume at usual doses as soon as symptoms improve and normal eating resumes (100% consensus) 1, 2

2. Volume-depleting medications (diuretics, ACE inhibitors/ARBs): Resume at usual doses within 24-48 hours of eating and drinking normally (95% consensus) 1, 2

3. Other medications (metformin, SGLT2 inhibitors): Resume at usual doses within 24-48 hours of eating and drinking normally (95% consensus) 1

4. If symptoms last >72 hours: Seek assistance from healthcare provider about medication resumption (100% consensus) 1

Patient Education Essentials

All patients must understand:

• Which specific medications to stop and which to continue during illness 2
• How to recognize and treat hypoglycemia 2
• Proper glucose and ketone monitoring technique 2
• When to contact healthcare provider 2
• Never discontinue insulin for economic or other reasons 2

Common Pitfall: The most dangerous error is continuing SGLT2 inhibitors during illness, as they can cause diabetic ketoacidosis even with normal glucose levels, making the diagnosis more difficult and delaying treatment 2