Background 

People with diabetes do not necessarily become unwell more frequently than others. However, during intercurrent illness, blood glucose levels can rise significantly and increase the risk of diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and acute kidney injury (AKI). Appropriate sick day advice can help prevent hospital admission and reduce the risk of complications. 

​

Aims of Sick Day Management 

• Maintain safe blood glucose levels 

• Ensure adequate hydration 

• Maintain carbohydrate intake 

• Monitor and manage ketones where appropriate 

• Recognise when urgent medical review is required 

​​

When Should Sick Day Advice Be Given? 

• Common cold 

• Influenza 

• Gastroenteritis (vomiting and diarrhoea) 

• Urinary tract infection 

• Chest infection 

• Pneumonia 

• Abscess 

• Injury or trauma (e.g. fracture) 

 

What medications to consider holding - SADMAN Rules 

Temporarily stop the following medicines during acute illness if there is a risk of dehydration: 

​

• S - SGLT2 inhibitors: Increased risk of euglycaemic DKA 

• A - ACE inhibitors: Increased risk of AKI 

• D - Diuretics: Increased risk of AKI 

• M - Metformin: Increased risk of lactic acidosis 

• A - ARBs: Increased risk of AKI 

• N - NSAIDs: Increased risk of AKI 

​​

SICK Guidance 

 

S = Sugar 

• Increase frequency of blood glucose monitoring. 

• Temporary increases in insulin or sulfonylurea doses may be required. 

 

I = Insulin 

• NEVER stop insulin. 

• Insulin requirements commonly increase during illness. 

 

C = Carbohydrate 

• Maintain hydration and carbohydrate intake. 

• Use carbohydrate-containing fluids if unable to eat. 

 

K = Ketones 

• In Type 1 diabetes check ketones every 4-6 hours during illness. 

• Increase fluids and follow ketone correction advice. 

 

Red Flags: Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic State (HHS)

• Excessive thirst 

• Polyuria 

• Dehydration 

• Shortness of breath 

• Abdominal pain 

• Nausea and vomiting (consider DKA symptom cf infective)

• Confusion or drowsiness 

​​​

Admission advised: Contact the Acute GP Service for urgent assessment and admission advice

​

References

Down S. How to advise on sick day rules. Diabetes & Primary Care. 2020;22:47-48. [dotn024ae8...b98e9b6d92 | PDF]

NICE NG28: Type 2 Diabetes in Adults.

TREND-UK Sick Day Rules resources.

Think Kidneys: Sick Day Guidance.