An international panel of clinicians has provided consensus recommendations on sick day medication for patients with diabetes mellitus, chronic kidney disease, or cardiovascular disease experiencing an acute illness.

Use of particular medications during acute dehydrating illness may contribute to hypotension, acute kidney injury (AKI), diabetic ketoacidosis, hypoglycemia, and related illnesses. In severe cases, complications can lead to hospitalization and death.

Writing in the American Journal of Kidney Disease, the 26-member panel from 10 clinical disciplines offered 42 recommendations for acute illness based on 75% or higher consensus. These included signs and symptoms accompanying volume depletion that should trigger medication changes, signs that should prompt urgent contact with a health care provider, and strategies for patient self-management.

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Volume depletion signs that require medication changes include significant vomiting or diarrhea, nausea or no eating, lightheadedness, dizziness, or fainting, weight loss of 3 kg within 2 days, and decreased urine output.

The panel agreed that prompt contact with a health care provider is crucial when a patient experiences confusion or reduced consciousness, vomiting more than 4 times in 12 hours, inability to retain fluids, low blood pressure, increased heart rate, or fever. For patients taking sodium-glucose cotransporter-2 (SGLT2) inhibitors or insulin, moderate or high ketones require urgent health care attention. Difficulty breathing and reduced consciousness are emergencies.

Patients should receive instruction to reverse volume depletion or dehydration and avoid hypoglycemia or ketoacidosis. Insulin users should monitor blood glucose every 4 to 6 hours. Patients taking SGLT2 inhibitors or insulin or following ketogenic diets should check ketones. Patients who took their daily dose of a sulfonylurea, should eat to prevent low blood sugar until the medication has worn off, usually within 12 to 24 hours.

The panel reached consensus that renin-angiotensin system inhibitors, diuretics, non-steroidal anti-inflammatory drugs, SGLT2 inhibitors, and metformin should be temporarily stopped during acute illness. They recommended that insulin, sulfonylureas, and meglitinides be withheld only if blood glucose is low. Basal and bolus insulin should be increased by 10% to 20% if blood glucose is high. They agreed to resuming medications within 24 to 48 hours of symptom resolution and a return to normal eating and drinking.

“These recommendations can be used to identify information for inclusion in clinician and patient facing resources and inform future studies to investigate the effectiveness of [sick day medication guidance] within clinical care and patient self-management strategies,” according to the panel.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Watson KE, Dhaliwal K, Robertshaw S, et al. Consensus recommendations for sick day medication guidance for people with diabetes, kidney, or cardiovascular disease: A modified delphi process. Am J Kidney Dis. 2022 Dec 2;S0272-6386(22)01054-X. doi:10.1053/j.ajkd.2022.10.012