Do blood pressure (BP) controlling medications need to be stopped if a patient is sick?

Blood Pressure Medications During Acute Illness: When to Stop

Yes, certain blood pressure medications should be temporarily stopped when a patient is acutely ill with signs of volume depletion (vomiting, diarrhea, reduced oral intake), but this applies specifically to ACE inhibitors/ARBs, diuretics, and ARNIs—not all BP medications. 1

Which BP Medications to Stop During Illness

Temporarily discontinue for up to 3 days or until symptoms resolve:

• ACE inhibitors/ARBs (e.g., lisinopril, losartan) - 90% consensus 1
• All diuretics:
  • Loop diuretics (e.g., furosemide) - 95% consensus 1
  • Thiazide/thiazide-like diuretics (e.g., hydrochlorothiazide, indapamide) - 90% consensus 1
  • Potassium-sparing diuretics (e.g., spironolactone, amiloride) - 95% consensus 1
• ARNIs (sacubitril/valsartan) - 88% consensus 1
• Direct renin inhibitors (aliskiren) - 82% consensus 1

Critical Exception: Beta-Blockers

Never stop beta-blockers abruptly, even during illness. 2 The FDA explicitly warns that abrupt discontinuation in patients with coronary artery disease can cause severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. 2 If dose reduction is absolutely necessary due to symptomatic hypotension, taper gradually over 1-2 weeks. 2, 3

When to Trigger This "Sick Day" Protocol

Stop these medications when the patient has new or worsening symptoms indicating volume depletion: 1

• Vomiting (>4 episodes in 24 hours) or diarrhea causing significant fluid loss 1
• Reduced oral intake preventing adequate fluid replacement 1
• Symptomatic hypotension (BP <90/60 mmHg or dizziness/lightheadedness) 4
• Fever >101°F (38.3°C) 4

Do not stop medications for minor illnesses like a simple cold or runny nose where the patient can maintain normal fluid intake. 1

When to Resume Medications

Restart volume-depleting medications (ACE inhibitors/ARBs, diuretics) at usual doses within 24-48 hours of eating and drinking normally. 1, 4 Do not wait longer than 3 days total unless symptoms persist, in which case contact the healthcare provider. 1

Monitoring Requirements During Illness

• Check blood pressure at home if possible 1
• Monitor for worsening symptoms 1
• Increase fluid intake to 8 oz every hour while awake 4
• Consider electrolyte replacement solutions 1

When to Seek Immediate Medical Attention

Call 911 or go to emergency department for: 1, 4

• Difficulty or rapid breathing (100% consensus) 1
• Reduced consciousness or new confusion (96% consensus) 1
• BP <90/60 mmHg with symptoms 4
• Heart rate >100 bpm at rest 4
• Symptoms lasting >72 hours despite stopping medications 1

Common Pitfalls to Avoid

Do not stop all BP medications simultaneously. If multiple agents need adjustment, address them systematically based on the categories above. 3 Calcium channel blockers (e.g., amlodipine) are generally not included in sick day guidance and can be continued unless specifically causing symptomatic hypotension. 1

Do not apply this guidance to patients with severe baseline hypertension (SBP ≥180 or DBP ≥110 mmHg) or those with recent cardiovascular events, as they require continuous BP control. 3

Clonidine and other central alpha-agonists also require gradual tapering if discontinuation is necessary, as they can cause dangerous rebound hypertension within 24-72 hours of abrupt cessation. 3, 5

Special Considerations for Patients with Diabetes

If the patient also has diabetes, additional medications require adjustment during illness: temporarily stop SGLT2 inhibitors (96% consensus) and metformin (86% consensus) to prevent diabetic ketoacidosis and lactic acidosis. 1, 4