What medications should be taken on a sick day?

Sick Day Medication Management

During acute illness with signs of volume depletion (vomiting, diarrhea, reduced oral intake), patients with diabetes or cardiovascular disease must temporarily stop specific medications while continuing insulin and diabetes monitoring, increase fluid intake to 8 oz per hour while awake, and resume stopped medications within 24-48 hours of normal eating and drinking. 1, 2

Medications to STOP Temporarily (Hold for up to 3 days or until symptoms resolve)

High Priority - Stop Immediately

• ACE inhibitors/ARBs: Temporarily discontinue with 90% expert consensus due to risk of hypotension and acute kidney injury during volume depletion 1
• All diuretics (loop, thiazide/thiazide-like, potassium-sparing): Stop with 95% consensus for loop and potassium-sparing types 1
• SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): Stop immediately with 96% consensus due to high risk of diabetic ketoacidosis even with normal glucose levels 3, 2
• Metformin: Discontinue with 86% consensus to prevent lactic acidosis during dehydration and acute kidney injury 3, 2
• ARNIs (sacubitril/valsartan): Stop with 88% consensus 1

Additional Medications to Hold

• Direct renin inhibitors (aliskiren): Stop with 82% consensus 1
• NSAIDs: Temporarily discontinue 2
• Sulfonylureas and meglitinides: Hold until blood glucose recovers to prevent hypoglycemia 2

Medications to CONTINUE

Insulin therapy must never be stopped during acute illness 3. This is critical to prevent diabetic ketoacidosis, particularly in type 1 diabetes 3.

• Continue basal insulin at usual or increased doses 2
• If blood glucose is elevated, increase basal and bolus insulin by 10-20% empirically 2
• DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin) are generally well tolerated and can be continued 3

Triggering Symptoms for Sick Day Protocol

Green Light (Self-Management Appropriate)

• Mild symptoms with ability to maintain fluid intake 3
• Patient feels capable and has support 3

Yellow Light (Contact Healthcare Provider)

• New or worsening vomiting resulting in significant fluid loss (>4 episodes) 3
• New or worsening diarrhea with fluid loss 3
• Reduced oral intake preventing adequate hydration 3
• Nausea interfering with fluid replacement 3

Red Light (Seek Immediate Medical Attention)

• Reduced consciousness or new confusion 1, 2
• Blood pressure <90/60 mmHg with symptoms 1, 2
• Heart rate >100 bpm at rest 1, 2
• Difficulty or rapid breathing 1
• Fever >101°F (38.3°C) that persists 2
• Moderate-to-large ketones present 2
• Symptoms lasting >72 hours despite stopping medications 1, 2

Monitoring Requirements During Illness

For Patients with Diabetes

• Increase blood glucose monitoring to every 2-4 hours (or use continuous glucose monitoring) 3, 2
• Check blood or urine ketones when glucose >300 mg/dL 2
• Monitor for signs of diabetic ketoacidosis even with normal glucose if taking SGLT2 inhibitors 2

For All Patients

• Monitor blood pressure at home if possible 1
• Watch for worsening symptoms 1
• Track fluid intake and output 3

Hydration Strategy

Drink 8 oz of fluid every hour while awake 1, 2. This aggressive fluid replacement is essential as dehydration doubles mortality risk in acute illness 4.

• Consume easily digestible liquids containing both carbohydrates and salt 2
• Adequate fluid intake is particularly critical for patients with diabetes who face increased dehydration risk from osmotic diuresis 5
• During acute illness, testing plasma glucose and ketones while drinking adequate fluids and ingesting carbohydrate are all important 3

Common Pitfall: While hydration is beneficial, be aware that excessive fluid intake in the setting of inappropriate ADH secretion during illness can rarely cause hyponatremia 6. However, the evidence strongly favors aggressive hydration, with moderate-quality evidence showing doubled mortality with dehydration 4.

Resuming Medications After Recovery

Restart medications systematically once eating and drinking normally 2:

• Within 24-48 hours: Resume ACE inhibitors/ARBs, diuretics, and other volume-depleting medications at usual doses 1, 2
• As soon as symptoms improve: Resume medications causing hypoglycemia (sulfonylureas, meglitinides) at usual doses once normal eating resumes 2
• Continue throughout: Insulin should never have been stopped 3

Patient Education Essentials

Patients must understand 2:

• Which specific medications to stop (write them down by name)
• Which medications to continue (especially insulin)
• How to recognize and treat hypoglycemia
• Proper glucose and ketone monitoring technique
• When to contact a healthcare provider versus seeking emergency care
• That sick day medication guidance is temporary only - medications must be resumed when illness resolves 3

Critical Caveat: This guidance applies to acute illness with volume depletion. It does not apply to minor illnesses without vomiting, diarrhea, or reduced intake 3. The evidence base for sick day guidance remains limited, and recommendations prioritize safety over definitive efficacy data 3.