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.

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.

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).

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.

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.

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.

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.