In time for the season! Have you ever wondered about how acute illness impacts chronic medication usage? What do we tell our "sick" patients upon discharge?
Joanne Routsolias PharmD
Bedside Clinical Question:
When discharging patients from the ED, what should we tell them about managing their chronic medications while they are acutely ill? What are "Sick Day Rules"
Background:
Acute illnesses can impair drug absorption, metabolism, and elimination. Unfortunately, this can lead to drug accumulation, toxicity, or therapeutic failure.
Risk of adverse drug effects increase during acute illness, especially in vulnerable patients such as: CKD, DM, HF and Elderly.
Hypovolemia and renal impairment are common triggers for medication-related adverse effects during an acute illness.
Some medications cause harm if continued, while others cause problems if abruptly stopped during an acute illness.
"Sick Day" medication rules may lessen adverse drug effects during acute illnesses.
Answer:
Below are some "rules" to follow in terms of medication management during acute illnesses.
First, assess key factors like severity and duration of illness, risk of dehydration or hypotension, comorbidities, drug class and formulation (especially extended release)
Consider temporarily withholding the following during significant illness if patient is at high risk for dehydration;
ACEI and ARBs
Diuretics
DM meds: Metformin, Sulfonylureas and SGLT2 inhibitors
NSAIDs
Watch medications requiring monitoring;
Insulin – may require a dose increase or decrease, not cessation
Sulfonylureas – continue with frequent BG monitoring; stop if hypoglycemia occurs
Beta blockers – avoid abrupt cessation (risk of rebound HTN)
Digoxin and lithium – monitor closely for toxicity if dehydration or ARF occurs
Issues with extended release formulations;
Reduced absorption in diarrhea may cause withdrawal or symptom relapse
Others;
Corticosteroids – consider increase dose temporarily (stress dosing)
Oral contraceptives – reduced absorption may cause contraceptive failure; use other barriers
Anticoagulants and AEDs – reduced absorption or cessation increases risk of clots or seizures
Antibiotics – continue if possible, to avoid resistance or failure
Provide discharge patient education such as;
Provide a "sick day" medication plan
Advise when to adjust, stop or restart medicines
Encourage increased monitoring (ex; BG and BP)
Advise when to seek medical attention if experiencing a drug adverse effect
Conclusion:
Careful medication management during acute illness is critical, especially in patients with comorbidities.
Temporary withholding or adjustment of certain medications can prevent serious complications.
Patient education through “sick day rules” improves safety and limits the risk of adverse drug effects.
References:
Tom N Lea-Henry, et al. Australian Prescriber, October 2017, Volume 40(5), pp. 168–173.
Dhaliwal KK, et al. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy. 2023;26(4):1746-1756.
Holt RIG, et al. Diabetes Care. 2021;44(11):2589-2625. doi:10.2337/dci21-0043.
Authored by Joanne Routsolias PharmD