Sick day management in CKM conditions

• Intercurrent illness can cause significant morbidity and mortality in people with CKM conditions, particularly at risk populations. Therefore, it is important everyone with CKM conditions have a management plan for sick days with basic advice on how to stay well and what to do with their medications.
  • Populations with CKM conditions at risk of adverse events from intercurrent illness:
    • Heart failure and other cardiac disease
    • Chronic kidney disease → especially if on dialysis
    • Diabetes → especially if type 1 diabetes or treated with insulin or sulfonylureas and/or corticosteroids e.g. prednisone
    • Cognitive impairment
    • Frailty and/or elderly → especially if living alone
    • History of falls
    • Post transplant or other immunodeficiency states
    • Chronic corticosteroid use
    • Significant liver disease
    • Previous adverse sick day events e.g. acute kidney injury

• Basic advice to stay well includes:
  • Notifying somebody that they are unwell
  • Avoiding strenuous activity
  • Avoiding NSAIDs particularly if CKD, ACEi/ARB and/or thiazide use
  • Ensuring they stay hydrated e.g. 1 standard glass of water per hour
    • May need to adjust if on dialysis or heart failure etc.
  • To continue eating as per normal or light meals if not tolerated → especially if on insulin
  • To monitor glucose levels 3-4 times per day or immediately if symptoms of hypoglycaemia or hyperglycaemia if known diabetes
    • People with type 1 diabetes, pancreatogenic diabetes or previous DKA will also need to check ketone levels
  • When to contact an ambulance and when to contact the practice
    • Consider use of personal medical alarm and/or alerts if high-risk particularly if living alone, feeling unsafe or reduced access to phone.
• Advice on whether to reduce or stop medications depends on the medication and type of illness, particularly if at risk of:
  • Hypovolaemia from fever, vomiting and/or diarrhoea
  • Hyperglycaemia if underlying diabetes, prediabetes or steroid treatment
  • Hypoglycaemia if reduced oral intake on insulin and/or sulfonylureas
  • Ketoacidosis if on empagliflozin or if insulin-deficient diabetes

• Common medications used to treat CKM medications that need to be stopped on sick days include:
  • Empagliflozin → stop in all acute illnesses including at least 3 days before (includes day of) an elective procedure, low carb diet or bowel preparation.
  • Diuretics → typically need to stop if at risk of hypovolaema
  • BP lowering therapy → typically need to stop if at risk of hypovolaemia, particularly ACEi and ARB
  • Metformin, vildagliptin and GLP1Ra → stop in GI illness
  • Sulfonylureas → likely need to reduce or omit dose if reduced oral intake
  • Meal time insulin → likely need to reduce or omit dose if reduced oral intake
  • Basal and premixed insulin → important to continue but reduce dose by ~ 30%
    • People on large doses of insulin may need 40-50% reductions

• It is important that patients have a plan when to restart their medications because prolonged cessation of their medications may lead to deterioration of their CKM condition e.g. increasing glucose levels, decompensated heart failure etc.
  • General rule is to restart medications 48 hours after feeling better and eating and drinking normally.
  • May need to restart medications earlier if clinically required
• Beware of medications such as opioids, lithium and gabapentinoids that are renally cleared and may accumulate causing significant adverse effects.

• Managing glucose levels during sick days can be difficult due to the stress response of illness, the need to withhold glucose lowering therapies, altered oral intake, reduced physical activity and medication use e.g. corticosteroids. Insulin is often required to control resulting hyperglycaemia.
  • Detailed guidance on management of sick days in people with diabetes including use of correction insulin can be found here