Medication sick day guidance

There is a potential risk of harm to individuals taking certain medicines while experiencing a dehydrating illness (repeated vomiting or diarrhoea and/or fever, sweats and shaking). The aim of the Medication Sick Day Guidance is to prevent such adverse events by temporarily withholding medication during episodes of acute dehydrating illness and restarting once the individual is well.³⁰⁶ The temporary cessation of medication should not normally be for longer than 72 hours without seeking advice from a healthcare professional.

A person-centred approach should be used with the Medication Sick Day Guidance. Prior to provision, consider the individual’s risks and benefits of following the Medication Sick Day Guidance, as the guidance may not be suitable for some individuals, for example, those at risk of decompensating with left ventricular systolic dysfunction (LVSD).

Medication Sick Day Guidance may be appropriate for those taking one or more of the following medicines (and can be remembered with the SADMAN acronym):

• Sodium-glucose co-transporter-2 (SGLT-2) inhibitors
• Angiotensin-converting enzyme inhibitors (ACEI)
• Diuretics
• Metformin
• Angiotensin receptor blockers (ARB)
• Non-steroidal anti-inflammatory drugs (NSAID)
  
  Most medications will only be temporarily withheld until the individual has recovered, as they are required for the management of chronic conditions.²⁵ ACE inhibitors and diuretics in non-LVSD presentations, and NSAIDs may not be classed as essential medicines as per the Medicines to review table in step 2 of the 7-steps review process.

This list is not exhaustive, and healthcare professionals (HCP) can add medicines to the alert card, if there are concerns that an individual may come to harm if a specific medicine is continued during an acute dehydrating illness.^{306, 307, 308}

The advice for people prescribed sulfonylureas is complex. Individuals prescribed a sulfonylurea may be advised to withhold it, if their blood glucose is low. However, it is important to note that illness and infections, as well as other forms of stress, can significantly raise blood glucose levels even when not eating and drinking properly and the decision to continue or stop sulfonylureas should be based on the individual's blood glucose levels.

Generally:

• During dehydrating illness, the risk of acute kidney injury (AKI) may be increased by medications that lower blood pressure, reduce circulating volume or renal blood flow.
• The recommendation for temporary interruption of treatment is largely based on expert consensus and more research on the implementation and effectiveness of Medication Sick Day Guidance is required, particularly in the community setting.^{309,310,311,312}
• A person-centred approach should be used with Medication Sick Day Guidance. Targeted provision to those at high risk of AKI, based on an individual risk assessment may be a more suitable and pragmatic approach.^312,313
• In anticipation of a dehydrating illness, individuals at risk of AKI should be advised to seek healthcare professional advice on medication changes.³¹⁴
• The guidance may not be appropriate in those with moderate to severe LVSD, as these individuals can decompensate and require specialist management. Therefore, during dehydrating illness, it may be advisable to seek specialist advice for these individuals instead of providing Medication Sick Day Guidance.
• All individuals should be advised to contact a healthcare professional for review if acute illness persists for longer than 72 hours. For adults admitted to hospital, it is recommended that advice on when to restart medication should be included at discharge.

Medicine specific:

• Sulfonylureas: continuing these during a dehydrating illness may increase the risk of hypoglycaemia, particularly if food and fluid intake are reduced.³⁰⁷
• SGLT-2 inhibitors:
  • increase diuresis and may exacerbate volume depletion during intercurrent illness. SGLT-2 inhibitors should be taken with caution in people who have limited oral intake or severe dehydration. Withholding SGLT-2 inhibitors during dehydrating illness can be part of a diabetic ketoacidosis (DKA) prevention strategy.²⁰⁷
  • can also be associated with euglycaemic DKA. When an individual is hospitalised for major surgery or acute serious medical illness, SGLT-2 inhibitors should be temporarily stopped, and blood ketones monitored during treatment interruption. Treatment may be restarted when the ketone values are normal and the individual’s condition has stabilised.^209,315
• ACEI, ARBs and NSAIDs may impair renal function and exacerbate acute kidney injury in those with intercurrent illness. Temporarily withholding ACEI and ARBs during dehydrating illness should be considered.^306,316
• NSAIDs: careful consideration on their use in dehydrating illness should be balanced with the risk of AKI.
• Diuretics: can either directly cause dehydration or increase the likelihood of dehydration during intercurrent illness.²⁵
• Metformin: reduced clearance can increase the risk of adverse effects, such as lactic acidosis.^25,309

During an acute dehydrating illness, medication review is advised and consider implementation of the Medication Sick Day Guidance where appropriate.

Medication Sick Day Guidance is not always appropriate, for example, individuals with heart failure should discuss with their healthcare professional what they should do with their medicines in the event of a dehydrating illness.

Reasons to consider stopping temporarily

• Impaired renal function
• Dehydration
• DKA
• Adverse effects due to reduced medicine clearance (e.g. lactic acidosis)

Individuals at higher risk of temporarily stopping medication

• At risk of decompensating LVSD

Medication Sick Day Guidance involves temporary suspension of the specified medicine during a dehydrating illness. Medicines should normally restart when the individual is back to their baseline function and eating and drinking normally. For a minor acute illness this could be a few days. For a more serious illness, for example with hospital admission, this may be weeks.

Advice on when to restart specific medication should be provided upon discharge for people who have been admitted to hospital.

Note that deprescribing is outwith the scope of Medication Sick Day Guidance but regular review of medicines to ensure their continued need and effectiveness is recommended.

Supporting people who do not or cannot reduce/stop

• Counsel on the importance of maintaining fluid balance during dehydrating illness
• Where necessary, counsel relatives/carers on Medication Sick Day Guidance³⁰⁶
• Counsel on signs and risks of AKI³¹¹ including nausea or vomiting, diarrhoea, dehydration, urinating less than usual, confusion or drowsiness
• Where appropriate, counsel on signs and risks of DKA³¹¹ including rapid weight loss, nausea or vomiting, stomach pain, excessive thirst, fast and deep breathing, confusion, unusual sleepiness or tiredness, a sweet smell to the breath, a sweet or metallic taste in the mouth, or a different odour to urine or sweat³¹⁸

Specific areas/situations where medication may need to be introduced or increased

• Diagnosis of the cause of the dehydrating illness will guide appropriate management. A person-centred medicine review should be undertaken.
• Ensure individual/carer is clear about how and when to restart medication (if appropriate).

Does the person understand the outcomes of the review, including risk and benefits?

• Perform a risk-benefit assessment to determine the suitability of the advice for the individual considering comorbidities
• Definition of dehydrating illness (repeated vomiting/ diarrhoea and/or fever, sweats and shaking)
• Minor illness or a single episode of sickness and diarrhoea does not merit treatment cessation
• The rationale for pausing certain medicines during dehydrating illness
• The name of the medicine(s) they should withhold
• Temporarily withholding medication should not normally be for greater than 72 hours without seeking advice from a healthcare professional
• Medicines should be restarted once eating and drinking normally for 24 to 48 hours and no longer acutely unwell

Is drug therapy tailored to the individual?

• Advise individuals unable to identify their medicines, for example in a compliance aid, to speak with their community pharmacy team. Written medication descriptions and large font labels on compliance aids can be beneficial

Agree the plan

• Provision of Medication Sick Day Guidance should have a person-centred approach
• Clear understanding of the information provided should be checked with the individual
• To help avoid inappropriate treatment cessation, complete the Medication Sick Day Guidance online form on the Polypharmacy: Manage Medicines website or app, to provide individuals with a personalised list of their medicines to withhold.

• self-management/support tools
• decision aids

Resources for healthcare professionals and patients and carers

The Medication Sick Day Guidance resources developed with Healthcare Improvement Scotland, can be personalised with medicine names and an electronic copy saved, printed or emailed from the Manage Medicines app.

A downloadable wallet sized card has been developed for completion with an individual’s relevant medication. This card is available digitally and can be saved, printed or emailed.

Leaflets are available for healthcare professionals and for patients and carers, providing more details about the Medication Sick Day Guidance.

Autopopulation of electronic prescription dosing instructions

One method to implement the Medication Sick Day Guidance is to include the advice within the dosing instruction on the prescription. This provides a number of triggers to discuss with the individual the importance of temporarily stopping these medicines during a potentially dehydrating illness: when issuing the prescription at consultation, when the medicine is dispensed and when referring to the dosing instruction on the medicine pack.

Each GP IT system has a means of autopopulating the prescription with the Medication Sick Day Guidance, e.g. in EMIS, the formulary EFM-file can be edited to include this dosing instruction which will be installed in each practice as the file is updated; in Vision the dosing instruction can be set by each practice using the default doses functionality.

The Health Literacy Place provides communication tools and techniques, such as ‘Teach Back’ and ‘Chunk and Check’, that can be helpful when counselling individuals on Medication Sick Day Guidance.