From the Guidelines
Withholding oral antiglycaemic medications during infection is crucial to prevent serious complications, and the most recent evidence suggests that certain medications like sulfonylureas should be temporarily decreased or stopped during illness due to the risk of hypoglycemia, especially when interacting with commonly used antimicrobials 1. When experiencing an infection with symptoms such as fever, vomiting, diarrhea, or reduced oral intake, patients should contact their healthcare provider and consider stopping these medications until they recover.
Key Considerations
- Metformin should be withheld due to increased risk of lactic acidosis during dehydration or acute illness.
- SGLT-2 inhibitors can increase the risk of dehydration and diabetic ketoacidosis during illness.
- Sulfonylureas may cause hypoglycemia when food intake is reduced, and their interaction with certain antimicrobials can dramatically increase the risk of hypoglycemia 1. During this time, patients should:
- Monitor blood glucose more frequently (every 2-4 hours).
- Stay hydrated.
- May need temporary insulin therapy to manage hyperglycemia. Once the infection resolves and normal eating and drinking resume, oral medications can typically be restarted.
Patient Categories
According to the standards of medical care in diabetes-2021, different patient categories have been proposed for diabetes management in those with advanced disease, including stable patients, patients with organ failure, and dying patients 1.
- For stable patients, the focus should be on preventing hypoglycemia and managing hyperglycemia.
- For patients with organ failure, preventing hypoglycemia is of greater significance, and dehydration must be prevented and treated.
- For dying patients, the discontinuation of all medications may be a reasonable approach, as patients are unlikely to have any oral intake. However, the most recent evidence from 2024 suggests that clinicians should reevaluate diabetes treatment during intercurrent illness and make adjustments as appropriate, including temporarily decreasing or stopping sulfonylureas when certain antimicrobials are prescribed 1.
From the FDA Drug Label
When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection or surgery, a loss of control may occur. At such times it may be necessary to discontinue glyburide tablets and administer insulin The patient should withhold oral antiglycaemic during infection, as loss of control of blood glucose may occur, and it may be necessary to discontinue the oral medication and administer insulin instead 2.
From the Research
Withholding Oral Antiglycaemic During Infection
- The decision to withhold oral antiglycaemic during infection is not directly addressed in the provided studies 3, 4, 5, 6, 7.
- However, the studies suggest that good control of blood sugar in diabetic patients is a desirable goal in the prevention of certain infections and to ensure maintenance of normal host defense mechanisms that determine resistance and response to infection 4.
- Uncontrolled hyperglycemia can impair overall immunity of diabetic patients, making them more susceptible to infections 5.
- Some studies suggest that diabetic patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and that infectious diseases can impair metabolic control in patients with diabetes 7.
- In general, the management of infections in diabetic patients typically requires both antimicrobial treatment and surgery, and may involve adjusting the patient's diabetes treatment plan 6.
- There is no direct evidence to support withholding oral antiglycaemic during infection, but the treatment plan may need to be adjusted to manage the infection and maintain good blood sugar control 4, 7.