Sick Day Medication Guidance
Information for Healthcare Professionals
As health professionals one of our key aims is to reduce the risk of avoidable harm to our patients. Diabetes renal patients are at increased risk due to being on multiple medications, which may potentially result in harm when unwell. If patients are unable to maintain adequate fluid intake, or have an acute decline in renal function (eg. due to gastrointestinal upset or dehydration), they should be instructed to adjust their medications.
The main reasons for providing such advice are:
1) Drugs may increase the risk of decline in kidney function:
(i) Non-steroidal anti-inflammatory drugs (NSAIDs) impair renal auto-regulation by inhibiting prostaglandin-mediated vasodilation of the afferent arteriole and may increase the risk of AKI.
(ii) Blood pressure lowering drugs or diuretics can reduce overall glomerular perfusion and increase the risk of AKI. ACEIs and ARBs reduce systemic blood pressure and also cause vasodilatation of the efferent arteriole. This impairs renal auto-regulation and reduces glomerular perfusion pressure. Diuretics can exacerbate hypovolaemia and electrolyte disturbance. (Note: this group also includes the mineralocorticoid receptor antagonists, spironolactone and eplerenone, used frequently in heart failure.)
2) Drugs may accumulate as a result of reduced kidney function in AKI, and increase the risks of adverse effects:
(i) Metformin is associated with an increased risk of lactic acidosis in high risk patients.
(ii) Sulphonylurea drugs may have an increased risk of hypoglycaemia, as the drug is renally cleared.
Medication “Sick Day Guidance” patient information cards have been developed that list the medicines that should be temporarily stopped during illness that can result in dehydration (ie. vomiting, diarrhoea and fever).
(picture of card)
It is important for healthcare professionals to be aware that there are possible potential harms associated with the provision of “sick day” guidance, particularly if patients have not been clinically assessed and where it is unclear at what level of ill health the medication should be discontinued. These include:
1) Decompensated heart failure when diuretics are discontinued
2) Development of poorly controlled hypertension with cessation of antihypertensives
3) Patients may over-interpret the advice and stop their drug treatment even during minor illnesses
4) Patients may not re-start their drug treatment on recovery.
5) Patients may self-manage inappropriately and not seek professional help at an appropriate stage
6) Issues related to removing medication from dossette boxes, requesting new dossette boxes and up-titrating medication in dossette boxes
7) Adverse control of blood sugars following the cessation of antihyperglycaemics.
Patients should be advised to seek medical attention if their illness were to result in them being off their medications for a significant number of days. If they have been unwell for longer than 24-48 hrs they will need to have a blood test to ensure the renal function has recovered enough to restart medication the card.