Diabetes Sick Day Medication Adjustments with CKD

Key Points

• Never stop basal insulin completely in type 1 diabetes solely because the patient is not eating.
• Pause SGLT2 inhibitors during significant illness, dehydration, fasting, and other ketoacidosis-prone states.
• Hold metformin during AKI, significant dehydration, hypoxemia, shock, or sepsis.
• Poor oral intake increases sulfonylurea-related hypoglycemia risk, especially in CKD.
• Check ketones during illness when insulin deficiency or SGLT2-associated ketoacidosis is possible.
• Fluid advice must be individualized in advanced CKD or heart failure.
• Temporary medication holds need clear criteria for restarting.
• Persistent vomiting, ketosis, or inability to hydrate warrants urgent evaluation.

Algorithm

1. At baseline, create a written sick-day plan listing each diabetes, blood-pressure, and kidney medication.
2. During illness, increase glucose monitoring and check ketones when indicated.
3. Continue basal insulin and adjust correction or meal doses to glucose and intake.
4. Hold SGLT2 inhibitor and other drugs that are unsafe during dehydration or AKI according to the individualized plan.
5. Maintain fluids and carbohydrate intake as tolerated within any cardiac or renal restriction.
6. Seek urgent care for persistent vomiting, ketones, severe hyperglycemia, hypoglycemia, dyspnea, confusion, or reduced urine output.
7. Check electrolytes, bicarbonate, creatinine, and beta-hydroxybutyrate when clinically indicated.
8. Restart held medications only after recovery and, when needed, confirmation of stable kidney function.

Clinical Synopsis & Reasoning

People with diabetes and chronic kidney disease are vulnerable during vomiting, diarrhea, fever, poor intake, or dehydration because glucose can rise from stress while renal clearance of insulin and medications changes unpredictably. The same illness can cause hypoglycemia when intake falls or hyperglycemia and ketosis when counterregulatory hormones rise. A sick-day plan should therefore be written before illness occurs and should specify which medicines to continue, which may need temporary interruption, when to check ketones, and when to seek urgent care.

Insulin should generally not be stopped in a person with type 1 diabetes, even when food intake is poor, because complete insulin omission can precipitate diabetic ketoacidosis. Basal insulin usually continues, with correction and prandial doses adjusted to glucose and carbohydrate intake. People using SGLT2 inhibitors should pause the drug during significant acute illness, prolonged fasting, dehydration, or before major surgery because of risk for euglycemic ketoacidosis. Metformin should be held during significant dehydration, hypoxemia, shock, sepsis, or acute kidney injury because these conditions increase the risk of accumulation and lactic acidosis.

RAAS blockers and diuretics may need temporary interruption when a patient is clearly volume depleted or hypotensive, but indiscriminate stopping can destabilize heart failure or hypertension. Decisions should be individualized. NSAIDs should be avoided during dehydration because they impair renal autoregulation. Sulfonylureas may need to be reduced or held if oral intake is poor, especially in CKD where hypoglycemia can be prolonged. GLP-1 based therapies may be held when persistent vomiting or inability to maintain hydration is present.

Treatment Strategy & Disposition

During illness, increase glucose monitoring frequency. Patients at risk for insulin deficiency should check blood or urine ketones when glucose is persistently high, when nausea or vomiting occurs, or when they feel unwell even with a glucose that is not markedly elevated if they use an SGLT2 inhibitor. Encourage frequent small amounts of fluid and carbohydrate-containing fluids when solid food is not tolerated, matching insulin to intake. Patients with fluid restrictions from advanced CKD or heart failure need individualized instructions rather than a generic 'drink plenty of water' message.

Urgent evaluation is required for persistent vomiting, inability to keep fluids down, moderate or large ketones, progressive dyspnea, confusion, severe weakness, chest pain, hypotension, or glucose that remains very high despite correction insulin. CKD lowers the threshold for laboratory testing because potassium, bicarbonate, and creatinine can change quickly. When euglycemic DKA is possible, obtain a metabolic panel, anion gap, venous blood gas, and beta-hydroxybutyrate even if glucose is below 250 mg/dL.

Medication restart should occur only after the acute illness has resolved, hydration and oral intake are restored, and kidney function is stable when relevant. SGLT2 inhibitors should not be restarted if ketoacidosis remains unresolved or the precipitating risk persists. Metformin should resume only when contraindicating conditions have cleared. Provide the patient with a written plan and a contact number; sick-day rules that exist only in the clinician's note are unlikely to prevent an emergency.

Epidemiology / Risk Factors

• Diabetes and CKD frequently coexist, and acute illness is a common precipitant of emergency visits for dysglycemia and AKI.
• Older adults and patients with advanced CKD are at especially high risk for medication accumulation and hypoglycemia.
• SGLT2 inhibitor use has expanded because of kidney and cardiovascular benefits, making sick-day ketoacidosis counseling increasingly important.
• Many adverse events occur because patients are told what to stop but not when to restart.

Investigations

When to Pause

Pharmacology

Prognosis / Complications

• Most short illnesses can be managed safely at home when the patient has a clear plan and can monitor glucose and hydration.
• Delayed recognition of DKA, severe hypoglycemia, or AKI can lead to hospitalization and permanent kidney loss.
• Repeated sick-day AKI episodes accelerate CKD progression.
• Good education reduces medication-related complications without sacrificing the long-term kidney and cardiovascular benefits of indicated therapies.

Patient Education / Counseling

• Keep a written medication list that marks which drugs may need temporary interruption.
• Stock glucose treatment, ketone strips, and backup insulin supplies before illness occurs.
• Call early if vomiting prevents medications or fluids from staying down.
• Do not restart held drugs simply because a calendar day has passed; restart when hydration, intake, and kidney status are appropriate.
• Ask the diabetes or kidney team for a personalized fluid target if heart failure or advanced CKD is present.
• Teach family members the signs of DKA, severe hypoglycemia, dehydration, and altered mental status.

Notes

The phrase 'SADMANS' is sometimes used to teach sick-day medication holds, but mnemonic-based care can be too blunt. A patient with decompensated heart failure may be harmed by stopping a diuretic, while a dehydrated patient may be harmed by continuing it. The decision should track physiology, not merely a medication list.

The most important safety message is that temporary holds are temporary. Long-term discontinuation of evidence-based SGLT2 inhibitors or RAAS blockade after a brief illness can deprive patients of substantial kidney and cardiovascular benefit.

References

1. KDIGO Diabetes and CKD Guideline — Link
2. ADA Standards of Care in Diabetes 2026 — Link