Sick Day Rules 🏥
Sick day rules for inpatients: when to hold SADMANS, manage diabetes and steroids on the ward, and when to escalate. For NCHDs.
📋 Why This Matters on the Ward
- Acutely unwell or fasting inpatients on diabetes medications or long-term steroids need specific drug adjustments to reduce DKA (especially with SGLT2i), lactic acidosis (metformin), AKI (ACEi/ARB/diuretics/NSAIDs when volume depleted), and adrenal crisis.
- Review drug charts daily: hold SADMANS when indicated; restart when the patient is eating and drinking, euvolaemic, and clinically improving. Document holds and restart clearly.
🔤 SADMANS – Medications to Consider Holding in Acutely Unwell or Fasting Patients
- When your inpatient is acutely ill (e.g. sepsis, vomiting, diarrhoea, dehydration, NBM, poor intake), consider holding the following until eating and drinking normally and volume replete. Restart when clinically appropriate; document and follow local policy.
S
- Medication Class
- SGLT2 inhibitors (e.g. empagliflozin, dapagliflozin, canagliflozin)
- Reason to Hold
- Risk of euglycaemic DKA when fasting or volume depleted. Hold when NBM or before contrast/surgery.
A
- Medication Class
- ACE inhibitors (e.g. ramipril, lisinopril)
- Reason to Hold
- Risk of AKI when volume depleted; hyperkalaemia.
D
- Medication Class
- Diuretics (e.g. furosemide, bendroflumethiazide)
- Reason to Hold
- Worsen dehydration and AKI; electrolyte disturbances.
M
- Medication Class
- Metformin
- Reason to Hold
- Risk of lactic acidosis when dehydrated, hypoxic, or in acute illness (e.g. sepsis). Hold when NBM or before IV contrast as per local policy.
A
- Medication Class
- ARBs (e.g. losartan, candesartan)
- Reason to Hold
- Same as ACEi: AKI and hyperkalaemia when volume depleted.
N
- Medication Class
- NSAIDs (e.g. ibuprofen, naproxen)
- Reason to Hold
- Reduce renal perfusion; increased AKI risk when volume depleted.
S
- Medication Class
- Sulfonylureas (e.g. gliclazide, glimepiride)
- Reason to Hold
- Risk of hypoglycaemia when not eating. Hold if poor intake or NBM; continue insulin and adjust dose (often need more when unwell).
| Letter | Medication Class | Reason to Hold |
|---|---|---|
| S | SGLT2 inhibitors (e.g. empagliflozin, dapagliflozin, canagliflozin) | Risk of euglycaemic DKA when fasting or volume depleted. Hold when NBM or before contrast/surgery. |
| A | ACE inhibitors (e.g. ramipril, lisinopril) | Risk of AKI when volume depleted; hyperkalaemia. |
| D | Diuretics (e.g. furosemide, bendroflumethiazide) | Worsen dehydration and AKI; electrolyte disturbances. |
| M | Metformin | Risk of lactic acidosis when dehydrated, hypoxic, or in acute illness (e.g. sepsis). Hold when NBM or before IV contrast as per local policy. |
| A | ARBs (e.g. losartan, candesartan) | Same as ACEi: AKI and hyperkalaemia when volume depleted. |
| N | NSAIDs (e.g. ibuprofen, naproxen) | Reduce renal perfusion; increased AKI risk when volume depleted. |
| S | Sulfonylureas (e.g. gliclazide, glimepiride) | Risk of hypoglycaemia when not eating. Hold if poor intake or NBM; continue insulin and adjust dose (often need more when unwell). |
📝 Inpatient Diabetes Management When Unwell
- Hold SADMANS as above. Do not stop insulin – continue and adjust (often need more when unwell; use sliding scale or basal–bolus as per local protocol).
- Monitor CBG regularly (e.g. 4–6 hourly or more if unstable). Check capillary or urine ketones if type 1, on SGLT2i, or if glucose high and unwell – escalate if ketones rising.
- Ensure adequate IV or oral fluids; avoid hypoglycaemia. Involve diabetes team if glucose difficult to control or if unsure about insulin dosing.
🚨 When to Escalate
- Rising or significant ketones (e.g. ≥1.5–3 mmol/L or ++) with high glucose or unwell – possible DKA; senior review and consider DKA protocol.
- Hypoglycaemia not responding to treatment or recurrent; consider holding sulfonylurea and reviewing other glucose-lowering meds.
- Suspected adrenal crisis (on long-term steroids, hypotensive, unwell, vomiting) – give hydrocortisone 100 mg IV/IM and senior/endocrine review.
- Uncertain about holding or restarting SADMANS, or complex diabetes – discuss with senior or diabetes team.
💊 Steroid Sick Day Rules (Inpatients on Long-Term Steroids)
- Patients on long-term steroids (e.g. prednisolone ≥5 mg daily for >3 weeks, or known adrenal insufficiency) are at risk of adrenal crisis when acutely unwell.
- Double the usual steroid dose during acute illness (e.g. infection, surgery, significant stress). Continue until recovered, then wean back to usual dose.
- If vomiting or NBM: give hydrocortisone IV/IM (e.g. 100 mg 6–8 hourly or as per local protocol); do not leave without steroid cover.
- Document steroid dose and sick-day adjustment in notes and in discharge summary; ensure patient and GP know to double steroids when unwell at home.
📌 Other Inpatient Situations
- NBM / fasting: hold SGLT2i, metformin, sulfonylureas; continue insulin with appropriate regimen. Hold ACEi/ARB/diuretics if volume depleted or AKI risk.
- Before IV contrast: hold metformin as per local policy (often 48 h before and after; check renal function before restarting). Hold SGLT2i before procedures involving fasting.
- Pre-op / procedures: hold SGLT2i and metformin as per anaesthetics guidance (often 24–48 h before). Restart when eating and drinking and renal function stable.
Educational reference only. Medical disclaimer