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Sick Day Rules — Medication Adjustment in Acute Illness SADMAN drugs to hold · diabetes sick-day rules · never stop insulin · SGLT2-inhibitor euglycaemic DKA · steroid sick-day dosing
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The full reasoning pathway — during any acute dehydrating illness, screen for the emergency, hold the SADMAN drugs that cause harm, never stop insulin, and give clear written sick-day & restart rules.StartDecisionInvestigateActionReferStop / Admit
PresentationAcute illness (D&V, fever, sepsis, reduced intake)
A patient on diabetes medication and/or "SADMAN" drugs who becomes acutely unwell — especially with vomiting, diarrhoea, fever or poor oral intake. Identify what they take and how unwell they are.
Step 1 · Safety — DKA / dehydration / can't copeEmergency features?
Vomiting and unable to keep fluids down · rising/large ketones · drowsy, deep breathing, abdominal pain (DKA) · marked dehydration / AKI · sepsis (NEWS2 ≥5) · very high glucose with HHS features in an older T2DM patient.
YES
Stop · Admit999 / same-day
Suspected DKA/HHS, can't keep fluids down, drowsy, or septic → emergency admission. Do not stop insulin en route.
NO — manageable at home
Step 2 · InvestigateGlucose · ketones · hydration
Check capillary glucose (more frequently, every 2–4h), blood/urine ketones if glucose >13–15 or unwell, fluid status. Review the full drug list.
Step 3 · which medicines need action?
HOLD — "SADMAN"
Pause until well & eating/drinking
Sulfonylureas/SGLT2i · ACE inhibitors · Diuretics · Metformin · ARBs · NSAIDs. Reduce AKI, hypo, lactic-acidosis & euglycaemic-DKA risk.
NEVER STOP — insulin
Continue, adjust by glucose/ketones
Illness raises glucose via stress hormones. Keep basal insulin going even if not eating; give correction doses per ketones/glucose.
INCREASE — steroids
Steroid sick-day rules
Adrenal insufficiency / long-term steroids → double oral hydrocortisone; IM hydrocortisone if vomiting.
Step 6 · ReferEscalation
999 / same-day DKA/HHS, persistent vomiting, drowsiness, rising ketones, AKI or sepsis. Diabetes team recurrent sick-day decompensation or insulin-adjustment uncertainty.
Step 8 · Self-management & preventionWritten sick-day plan + restart rules
Give every at-risk patient a written sick-day card: which drugs to hold, never to stop insulin, fluids/carbohydrate advice, when/how to check ketones, when to seek help, and restart held drugs after 24–48 h of eating and drinking normally.
Step 9 · Safety-netWhen to seek urgent help
999 / same-day if vomiting and can't keep fluids down, ketones rising despite extra insulin, drowsy/confused, deep rapid breathing, or unable to manage at home.
⚠️ Never stop insulin during illness — stopping it is the commonest avoidable cause of DKA. And stop SGLT2 inhibitors during any acute illness: they cause euglycaemic DKA where the glucose looks reassuringly normal.
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Safety

Red Flags — When Acute Illness Becomes an Emergency

Sick-day rules exist to prevent two killers — diabetic ketoacidosis (DKA) and acute kidney injury (AKI). Screen for them before deciding the patient is safe at home.

Vomiting + unable to keep fluids down Cannot follow oral sick-day rules → dehydration and ketosis escalate quickly. Same-day assessment; likely admission for IV fluids ± insulin.
Ketones rising / blood ketones ≥3 mmol/L (or 2+ on urine) + unwell Impending or established DKA. → 999. Do NOT stop insulin. IV fluids + fixed-rate insulin infusion in hospital.
Drowsy, confused, deep sighing (Kussmaul) breathing, abdominal pain, fruity breath Established DKA — medical emergency. → 999.
Older T2DM patient + very high glucose (often >30) + marked dehydration + drowsiness, low/no ketones Hyperosmolar hyperglycaemic state (HHS). → 999.
Reduced urine output, light-headed, postural drop after D&V — especially on ACEi/ARB/diuretic/metformin/NSAID Acute kidney injury. Hold the SADMAN drugs; check U&E; same-day if unwell.
NEWS2 ≥5, fever + rigors, looks septic Sepsis. → Sepsis pathway / same-day admission.
A normal blood glucose does not exclude DKA in a patient on an SGLT2 inhibitor — check ketones in anyone unwell on these drugs (euglycaemic DKA).
Acute illness raises counter-regulatory hormones (cortisol, catecholamines, glucagon, growth hormone) which drive hyperglycaemia and ketogenesis even when the patient is eating less. In type 1 diabetes, reduced or omitted insulin during this surge is the single commonest precipitant of DKA. Dehydration from vomiting/diarrhoea simultaneously reduces renal perfusion, and continuing nephrotoxic or renally-cleared drugs (the SADMAN group) tips borderline kidneys into AKI and, for metformin, raises the risk of lactic acidosis. Recognising who cannot be managed at home is the core safety skill the SCA tests.
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Diagnose

Identify Who Is at Risk — The Medication Review

Sick-day rules apply to three overlapping groups: people on insulin, people on the "SADMAN" drugs, and people on long-term steroids. Map the patient's drugs onto these.

Insulin (T1DM or T2DM)
Highest priority. Stress of illness raises glucose — insulin requirements usually rise, not fall, even with reduced eating.
SADMAN drugs
Sulfonylureas / SGLT2 inhibitors · ACE inhibitors · Diuretics · Metformin · ARBs · NSAIDs. Hold during dehydrating illness.
Long-term steroids / adrenal insufficiency
Need increased steroid (sick-day dosing), not a hold — see the dedicated Addison's/steroid pathway.
Other relevant drugs
Lithium (toxicity with dehydration — check level, ensure hydration), anticoagulants/DOACs (renal dosing), digoxin (toxicity if AKI/electrolyte shift).
The SADMAN mnemonic is a deliberately memorable shorthand for the drugs that either impair the kidney's ability to cope with dehydration (ACEi, ARB, diuretics, NSAIDs), accumulate dangerously in AKI (metformin → lactic acidosis), or cause harm when oral intake falls (sulfonylureas → hypoglycaemia; SGLT2 inhibitors → euglycaemic DKA and volume depletion). Reviewing the medication list against this group converts a vague "they're unwell" into a concrete action plan.
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Diagnose

Assess the Unwell Patient — What to Check

Before deciding home vs admit, quantify the two risks — ketosis (DKA) and dehydration (AKI) — and judge whether the patient can actually follow oral sick-day rules.

Blood glucose
Check now and 2–4 hourly; high glucose during illness means insulin needs to rise, not fall. A normal glucose does not reassure on an SGLT2 inhibitor.
Blood ketones
The key test: <0.6 normal · 0.6–1.5 recheck + extra fluids · 1.5–3 correction insulin + seek advice · ≥3 emergency. Test in anyone unwell on an SGLT2 inhibitor even if glucose is normal (euglycaemic DKA).
Hydration & U&E
Postural BP, urine output, capillary refill, mucous membranes. Check U&E if D&V on SADMAN drugs — and hold them if AKI is likely.
NEWS2 / sepsis
Fever with rigors, tachycardia, hypotension, NEWS2 ≥5 → sepsis pathway / same-day admission.
Can they follow the rules?
The pivotal question: is the patient keeping fluids down and able to monitor and correct at home? This, not the absolute glucose, decides home vs admit.
Assessment turns a vague “unwell diabetic” into two measurable risks: blood ketones track evolving DKA hours before the patient looks ill, and U&E plus hydration status track impending AKI — the two killers the rules exist to prevent. The single most decisive observation, though, is behavioural: a patient who can keep fluids down and follow their correction plan can usually be managed at home whatever the glucose, whereas one who is vomiting with rising ketones needs admission even if the glucose looks unalarming.
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Treat

Diabetes Sick-Day Rules — Never Stop Insulin

The core message for anyone on insulin: keep taking it, monitor more, stay hydrated, and watch ketones.

Never stop insulin
Continue basal insulin even if not eating. Stopping insulin is the commonest avoidable cause of DKA.
Monitor more often
Check blood glucose every 2–4 hours (including overnight if unwell).
Check ketones
Test blood (preferred) or urine ketones if glucose >13–15 mmol/L or feeling unwell. Blood ketones: <0.6 normal · 0.6–1.5 recheck/extra fluids · 1.5–3 give correction insulin + seek advice · >3 emergency.
Correction doses
Give extra rapid-acting insulin (often ~10–20% of total daily dose) per individual plan if glucose/ketones high; repeat 2-hourly with recheck.
Stay hydrated
Sip fluids regularly (aim ~3 L/day). If not eating, take sugary drinks to maintain carbohydrate if glucose is not high; water/sugar-free if glucose high.
SGLT2 inhibitors
Stop during acute illness — risk of euglycaemic DKA. Restart when well and eating/drinking normally.
Ketone monitoring is the early-warning system: a rising blood ketone level identifies evolving DKA hours before the patient looks unwell, allowing extra insulin and fluids at home to abort it. Patients are taught the "sick day" correction algorithm by their diabetes team; the GP's role is to reinforce it, ensure they have ketone strips and a plan, and recognise when home management is failing.
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Treat

SADMAN Drug Holds — What to Pause and When to Restart

During a dehydrating illness (vomiting, diarrhoea, fevers with poor intake), temporarily hold the SADMAN drugs.

Sulfonylureas
Hypoglycaemia risk if not eating — hold while intake is poor.
SGLT2 inhibitors
Stop — euglycaemic DKA and volume depletion.
ACE inhibitors / ARBs
Reduce renal perfusion in dehydration → AKI and hyperkalaemia. Hold.
Diuretics
Worsen dehydration and AKI. Hold.
Metformin
Accumulates in AKI → lactic acidosis. Hold.
NSAIDs
Nephrotoxic in dehydration. Hold (and avoid generally).
Restart rule
Restart held drugs once the patient has been eating and drinking normally for 24–48 hours. Recheck U&E before/after restarting ACEi/ARB/diuretic if AKI occurred.
Holding is temporary. Make sure the patient knows to restart — unintended permanent discontinuation of an ACEi after an admission is a common medicines-safety error.
Each SADMAN drug is safe in health but harmful in the specific physiology of acute dehydrating illness. Holding them for the duration of the illness removes that harm without meaningfully worsening the chronic conditions they treat. The restart step matters as much as the hold: documented, time-limited holds with a clear restart trigger prevent both the acute harm and the downstream harm of a chronically-needed drug being dropped by accident.
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Treat

Steroids — Sick-Day Dosing (Increase, Don't Hold)

Patients with adrenal insufficiency or on long-term steroids are the exception — illness means they need more steroid, not less.

Oral, intercurrent illness/fever
Double the usual oral hydrocortisone (or equivalent) for the duration of the fever/illness; return to normal once recovered.
Vomiting / can't take oral
Give IM hydrocortisone (emergency injection) and seek urgent help — anyone can give it.
Surgery / procedures
Need additional peri-procedure steroid cover — arrange in advance.
Equipment
Ensure steroid emergency card, MedicAlert and an in-date IM hydrocortisone kit.
In adrenal insufficiency the body cannot mount the physiological cortisol surge that illness demands; without extra exogenous steroid the patient can decompensate into an adrenal crisis (hypotension, collapse, hyponatraemia). This is the opposite instinct to the SADMAN holds, which is exactly why it is a high-yield exam discriminator — the same trigger (illness) demands "stop" for some drugs and "double" for steroids.
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Refer

When to Admit or Escalate

999 / same-day
Suspected DKA or HHS, persistent vomiting unable to keep fluids down, drowsiness/confusion, blood ketones ≥3, sepsis, severe dehydration/AKI, or adrenal crisis.
Discuss with diabetes team
Ketones rising despite correction doses, uncertainty about insulin adjustment, or recurrent sick-day decompensation.
Manage at home
Tolerating fluids, ketones controlled, glucose monitored, has a written plan and can seek help — safety-net clearly.
The admission threshold is set by the patient's ability to follow oral sick-day rules and by ketone trajectory, not by the absolute glucose. A patient with very high glucose who is alert, hydrating and clearing ketones can often be managed at home; a patient with near-normal glucose who is vomiting with rising ketones (e.g. on an SGLT2 inhibitor) needs admission.
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Lifestyle

Self-Management & Prevention — The Written Sick-Day Plan

Personalised sick-day card Which drugs to hold, never to stop insulin, and when to restart — written down, before they are ever ill.
Ketone testing kit Ensure insulin-treated patients have a blood-ketone meter, in-date strips, and know the action thresholds.
Fluids & carbohydrate Sip fluids regularly; sugary drinks if not eating and glucose not high; sugar-free if glucose high.
Annual reinforcement Revisit sick-day rules at diabetes/medication reviews and after any DKA admission.
Vaccination Annual flu, plus pneumococcal/COVID, to reduce illness episodes.
Restart reminder Reconcile medicines after illness so held drugs are restarted and not lost.
Sick-day rules only work if the patient knows them before they become unwell — when vomiting and frightened at 2am, nobody reads a leaflet for the first time. Proactive, written, personalised plans and ketone kits are the evidence-based way to prevent home illness from becoming a DKA admission.
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Safety

Follow-Up, Restart Rules & Safety-Netting

Safety-Netting — Tell Every Patient:

999 if
Persistent vomiting and can't keep fluids down, blood ketones ≥3, drowsiness/confusion, deep rapid breathing, abdominal pain, or collapse.
Same-day if
Ketones rising despite correction doses, glucose persistently very high or very low, reduced urine output, or feeling steadily worse.
Restart held drugs
Once eating and drinking normally for 24–48 h. Recheck U&E after an AKI before restarting ACEi/ARB/diuretic.
Reconcile
After any illness or admission, review the medication list so temporarily-held drugs are restarted and SGLT2 inhibitors resumed appropriately.
The two failure modes after a sick-day episode are under-escalation (a patient struggling at home who should have been admitted) and the silent medicines-safety error of a held drug never being restarted. Explicit, time-bound safety-netting and a deliberate medicines-reconciliation step close both gaps.
Educational use only. Pathway based on: TREND Diabetes / Diabetes UK Sick Day Rules · JBDS-IP Management of DKA & HHS in Adults · NICE CKS Diabetes — type 1 & type 2 · MHRA Drug Safety Update — SGLT2 inhibitors and DKA · NICE NG28 / NG17 · Society for Endocrinology / NICE NG243 Adrenal Insufficiency (steroid sick-day rules). Always adapt to individual patient context, local formulary, and current guidelines.