Diabetes Medication Sick Day Decision Tool
What symptoms are you experiencing?
What medications are you taking?
When youâre sick with a cold, flu, or stomach bug, your body is under stress. For people with diabetes, that stress can turn a simple illness into a medical emergency. Diabetic ketoacidosis (DKA) and acute kidney injury (AKI) arenât just rare complications-theyâre preventable, but only if you know exactly what to do with your medications when youâre not feeling well. Too many people assume they should keep taking all their pills the same way, even when vomiting or running a fever. Thatâs where things go wrong.
Why Illness Changes Everything for Diabetes Medications
Your body doesnât handle illness the same way it handles a normal day. When youâre sick, your liver pumps out extra glucose. Your muscles stop responding to insulin. Your kidneys struggle to filter waste. And if youâre not eating or drinking enough, your blood sugar can spike-or crash-without warning. The real danger isnât just high blood sugar. Itâs what happens when your diabetes meds interact with dehydration, fever, or vomiting.
Studies show people with diabetes are 3 times more likely to develop DKA and 2 times more likely to suffer AKI during illness than when theyâre healthy. In 2023, over 1.2 million diabetes-related hospital visits in the U.S. were tied to medication mismanagement during sickness. Thatâs not just a statistic-itâs someoneâs parent, sibling, or friend who ended up in the ER because they didnât know when to stop their pills.
Which Medications to Stop-and When
Not all diabetes medications are created equal when youâre sick. Some are safe to keep taking. Others can turn dangerous fast. Hereâs what you need to know, based on the latest ADA and IDF guidelines from 2023.
- Metformin: Stop immediately if youâre vomiting, have diarrhea, or have a fever over 100.4°F (38°C). Metformin builds up in your blood when your kidneys arenât flushing fluids properly. This raises your risk of lactic acidosis-a rare but deadly condition. Even if you feel fine, if you canât keep fluids down, stop metformin. Restart only after youâve been eating and drinking normally for 48 hours and your doctor says itâs safe.
- SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin): These must be stopped at the first sign of illness. Why? They make your body flush sugar out through urine-even when your blood sugar is normal. Thatâs called euglycemic DKA, and itâs sneaky. You might not feel your blood sugar is high, but your body is still making dangerous ketones. The FDA warns that delaying discontinuation by even 24 hours increases DKA risk by 300%. If youâre on one of these, keep them in your sick-day kit so you can toss them out fast.
- ACE inhibitors and ARBs (lisinopril, losartan, valsartan): These blood pressure meds protect your kidneys-but only when youâre hydrated. If youâre drinking less than 1,500 mL (about 6 cups) in 24 hours, pause them. They can cause your kidneys to shut down fast when youâre dehydrated. Check your urine output. If youâre peeing less than usual or your ankles are swelling, donât wait-call your doctor.
- Sulfonylureas (glimepiride, glyburide): These can cause dangerous lows during illness because youâre not eating. If youâre skipping meals, reduce the dose by 50% or stop until youâre eating regularly again. Donât guess-call your provider for advice.
Insulin: Donât Skip It-Adjust It
This is the biggest mistake people make: skipping insulin when theyâre sick. Thatâs like turning off your carâs brakes while driving downhill. Even if youâre not eating, your body still needs insulin to stop ketones from building up.
If you have type 1 diabetes, youâll likely need 10-20% more basal insulin every 4 hours when your blood sugar is above 15 mmol/L (270 mg/dL). Use your insulin pumpâs temporary basal feature, or give extra injections as your doctor taught you. Donât wait for your sugar to hit 300 or 400-act early.
If you have type 2 diabetes and take insulin, you might also need more. About 68% of people in a 2023 clinical trial needed higher doses during illness. But thereâs no one-size-fits-all rule. Track your numbers, and call your provider if your blood sugar stays above 240 mg/dL for more than 6 hours.
How to Monitor: Blood Sugar, Ketones, and Hydration
Monitoring isnât optional-itâs your lifeline.
- Check blood sugar every 2-4 hours. Set phone alarms if you have to. Six checks a day is the minimum. Write them down. Youâll need this info when you call your doctor.
- Test for ketones if your blood sugar is over 240 mg/dL. Use urine strips or a blood ketone meter. If your blood ketones are above 0.6 mmol/L, or urine ketones are moderate to large, call your doctor now. Donât wait until you feel worse.
- Drink fluids. Water, sugar-free electrolyte drinks, broth-anything to keep your body hydrated. Aim for at least 1,500 mL (6 cups) a day. If you canât keep fluids down, sip slowly every 10 minutes. Dehydration is the trigger for most complications.
- Watch for warning signs: fruity breath, fast breathing, confusion, dry skin, no urine for 8+ hours, or swelling in your legs. These arenât normal. Theyâre red flags.
What to Keep in Your Sick-Day Kit
Donât wait until youâre sick to prepare. Build your kit by October, before flu season hits.
- Glucose meter with 50+ test strips
- Ketone strips (urine or blood, minimum 10)
- 7-day supply of all your medications (in original bottles)
- Sugar-free drinks: water, diet soda, broth, electrolyte packets (Nuun, Pedialyte)
- Fast-acting carbs: juice boxes, glucose tabs, honey packets
- ADA Sick Day Log (print or save on your phone)
- Emergency contact list: your doctor, endocrinologist, pharmacy, and a trusted family member
People who use a sick-day kit are 78% less likely to end up in the hospital. Itâs not magic-itâs preparation.
When to Call 911 or Go to the ER
Some situations canât wait. Donât hesitate to get help if you have:
- Blood sugar below 70 mg/dL that doesnât improve after 30g of carbs
- Ketones above 1.5 mmol/L for more than 2 hours
- Vomiting for over 4 hours or diarrhea for over 6 hours
- Difficulty breathing, confusion, or extreme fatigue
- No urine output for 12 hours
These are not "wait and see" moments. DKA and AKI can kill within hours if untreated. Call 911 or go to the nearest ER. Tell them you have diabetes and youâre following sick-day rules.
Why Everyoneâs Giving You Different Advice
Confusion is common. The ADA says stop metformin with vomiting. The IDF says stop it for any illness. Your endocrinologist says keep it. Your pharmacist says stop. A Reddit post says itâs fine.
The truth? Guidelines arenât perfect. Experts disagree on insulin adjustments. Some clinics donât even have written protocols. A 2024 study found 41% of patients got conflicting advice from their primary care doctor versus their endocrinologist. Thatâs why you need to know the science behind the rules-not just the advice.
Ask your doctor: "Whatâs my specific plan for metformin, SGLT2 inhibitors, and my blood pressure meds if I get sick?" Write it down. Keep it with your sick-day kit. Donât rely on memory when youâre feverish and nauseous.
The Bottom Line: Preparation Saves Lives
Sick days donât have to mean hospital days. The difference between staying home and ending up in the ICU often comes down to one thing: knowing what to do with your medications before you get sick. You donât need to be a doctor. You just need to know the basics.
Stop metformin and SGLT2 inhibitors when youâre vomiting or dehydrated. Donât skip insulin. Test your ketones. Drink fluids. Know your warning signs. Have a plan written down. And if in doubt-call your provider. Youâre not overreacting. Youâre protecting your health.
By the time youâre too sick to think clearly, itâs too late to learn. Start today. Build your kit. Talk to your doctor. Write your plan. Because when youâre sick, your meds can save you-or hurt you. You get to choose which one.
Should I stop my metformin if I have a stomach bug?
Yes. If youâre vomiting, having diarrhea, or have a fever, stop metformin immediately. Your kidneys canât clear the drug properly when youâre dehydrated, which raises your risk of lactic acidosis. Donât restart until youâve been eating and drinking normally for at least 48 hours-and only after talking to your doctor.
Can I still take my blood pressure meds when Iâm sick?
It depends. ACE inhibitors and ARBs (like lisinopril or losartan) can cause acute kidney injury if youâre not drinking enough fluids. If youâre taking less than 1,500 mL (6 cups) of fluid in 24 hours, pause them. Resume once youâre drinking normally again and your urine output returns to normal. Always check with your doctor before restarting.
Do I need to check ketones if my blood sugar is normal?
Yes-if youâre on an SGLT2 inhibitor. These drugs can cause euglycemic DKA, where your blood sugar stays in the normal range but your body is still producing dangerous ketones. Test ketones if youâre sick, even if your sugar is under 240 mg/dL. Blood ketones above 0.6 mmol/L mean you need medical help.
What if I canât keep fluids down?
Sip small amounts every 10-15 minutes: water, broth, or sugar-free electrolyte drinks. If you canât keep anything down for more than 4 hours, call your doctor or go to the ER. Dehydration leads to AKI and makes DKA worse. IV fluids may be needed. Donât wait.
Should I skip insulin if Iâm not eating?
No. Even if youâre not eating, your body still needs insulin to stop ketone production. For type 1 diabetes, increase your basal insulin by 10-20% every 4 hours if your blood sugar is above 15 mmol/L (270 mg/dL). For type 2, check with your provider-some need more insulin during illness, even if theyâre not eating.
How do I know if Iâm developing AKI?
Signs include: urinating much less than usual, swelling in your legs or ankles, feeling unusually tired, or having nausea. If youâre on an ACE inhibitor or ARB and youâre dehydrated, your kidneys are at risk. Check your urine output. If you havenât peed in 8-12 hours, get medical help.
Is it safe to use over-the-counter cold medicine?
Be careful. Many cold medicines contain sugar, decongestants (which raise blood sugar), or alcohol. Choose sugar-free versions. Avoid decongestants like pseudoephedrine if your blood sugar is already high. Always check labels and ask your pharmacist: "Is this safe for someone with diabetes?"
What should I do if Iâm confused about my sick-day plan?
Call your endocrinologist or diabetes educator. If you canât reach them, call the ADA helpline at 1-800-DIABETES. Donât guess. Donât rely on internet advice. Your plan should be written down and reviewed with your care team at least once a year-ideally before flu season.
What to Do Next
Right now, open your medicine cabinet. Look at your diabetes and blood pressure meds. Do you know which ones to stop if you get sick? If not, write down your plan today. Print the ADAâs Sick Day Log. Pack your kit. Talk to your doctor. Make a list of your meds, your warning signs, and your emergency contacts.
Donât wait until youâre feverish and vomiting to figure this out. The best time to prepare is when youâre healthy. Because when youâre sick, you wonât have the energy to think clearly. But if youâve already planned it? Youâll be ready.
Stop metformin when sick. Period. No excuses. I saw my uncle end up in ICU because he kept taking it while vomiting. Don't be him.
I just want to take a moment to really sit with how terrifying it is that something as simple as a stomach bug can turn into a death sentence if you're diabetic and don't know the fine print on your meds. I mean, think about it-your body is basically screaming for help, but the very drugs meant to save you are quietly turning into poison because you didn't read the tiny footnote about dehydration. And we're supposed to just trust our doctors? But half the time they give conflicting advice. I spent three days in the ER last year because I kept my SGLT2 inhibitor on thinking, 'I'm not that sick.' Turns out, I was. Euglycemic DKA isn't a buzzword-it's a silent killer that doesn't even let your glucose spike to warn you. And now I keep ketone strips next to my toothbrush. Every. Single. Day.
You guys are doing AMAZING just by reading this and preparing! Seriously. This isn't just info-it's a lifeline. I started my sick-day kit last month and already used it when I got the flu. Tested ketones, stopped my glimepiride, kept sipping electrolytes, and stayed out of the hospital. YOU CAN DO THIS. Write it down. Print it. Stick it on your fridge. Your future self will thank you. đŞâ¤ď¸
so u stop metformin when u puke... but u still take insulin even if u eat nothing? yeah ok doc. i bet ur also tellin folks to drink 6 cups of water while throwin up. lol. but hey at least the ADA printed it so it must be gospel. #blessed
I just want to say... thank you. Seriously. This post saved me. Iâve been on metformin for 7 years and never knew about lactic acidosis risk during illness. I had a bad cold last week, and I stopped my meds right away, checked ketones twice a day, and called my endo before things got scary. I didnât panic-I had a plan. And Iâm alive because of it. If youâre reading this and youâre diabetic-please, donât wait until youâre sick to learn this. Print this. Share it. Save it. Your life matters.
Oh, so now weâre supposed to become amateur nephrologists and pharmacologists just to survive a cold? Brilliant. Let me just toss my ACE inhibitor like itâs expired milk while Iâm barfing into a bowl and simultaneously calculating my basal insulin adjustments with a glucose meter in one hand and a juice box in the other. Meanwhile, my doctorâs office is closed, my pharmacy wonât answer at 2 a.m., and my âsick-day kitâ is just a drawer full of expired strips and a vague sticky note that says 'do something.' This isnât healthcare-itâs a survival RPG with a side of medical gaslighting.
The casual dismissal of clinical nuance in this post is not only irresponsible-it is morally indefensible. To suggest that laypersons, many of whom are elderly, cognitively impaired, or socioeconomically disenfranchised, can reliably self-manage life-threatening medication adjustments during acute illness is to endorse systemic negligence under the guise of empowerment. The very premise that one can 'build a kit' and 'write a plan' ignores the structural failures of healthcare access, provider communication gaps, and the documented 41% discordance in guidelines cited within this very article. This is not preparation. This is performative self-help propaganda that absolves institutions of their duty to provide coherent, standardized, and accessible care.
bro this is gold. i had dka last year and no one told me about sglut2 thing. i thought normal sugar = safe. big mistake. now i keep ketone strips in my pocket. if u sick, stop metformin. drink water. dont skip insulin. call doc. simple. u got this. india here and same rules work. u not alone.