Mengyao Tang @tammyyaotang

Dr. Mengyao Tang is a research fellow at Massachusetts General Hospital, as well as a board-certified nephrologist who has a particular interest in the interplay of CKD, CVD, and diabetes. She is an AJKD Editorial Intern from 2022-2023. She is supported by an AHA postdoctoral grant to study glycemic variability as a novel risk factor for CVD in CKD patients.

The importance of sick day medication guidance (SDMG), defined as “withholding or adjusting specific medications in the setting of acute illness”, has been emphasized in the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline. The rationale seems intuitive at first—most medications can be double-edged swords: taken long-term for cardio-renal-metabolic disease, they are lifesaving and reduce progression to end-stage kidney disease (ESKD), hospitalization rate, and even mortality; however, in acute illness, the same medications can potentially contribute to or aggravate hypotension, acute kidney injury (AKI), or hypoglycemia.

However, 21^st century modern medicine is based on evidence rather than intuition. A fundamental question remains to be answered: does SDMG actually work in preventing or mitigating adverse events? In a systematic review conducted to assess the clinical evidence base for the effectiveness of SDMG, most of the identified documents were educational resources or guidelines, and there were very few primary research studies conducted to answer the question. Furthermore, no studies reported beneficial effects on clinical outcomes.

One challenge to studying the effectiveness of SDMG is that there is a lack of consensus on recommendations for SDMG among researchers and practicing clinicians. In a recent study published in AJKD, Watson et al. seek to develop standardized SDMG recommendations for people with chronic kidney disease (CKD), cardiovascular disease (CVD), or diabetes.

In this study using a modified Delphi process, an international panel of experts on SDMG recruited through purposive and snowballing sampling had a total of 3 rounds to develop, refine, and vote on recommendations via virtual meetings. They focused on 3 main questions:

1) What symptoms or signs of acute illness should trigger SDMG?

2) What should be included in SDMG?

3) What medication instructions should be included in SDMG?

Data were collected and analyzed using a mixed method, including counts and percentages to report agreement and consensus (75% agreement), as well as content analysis to capture contexts and additional considerations (Figure 1).

Modified Delphi Process Flow Diagram. Figure 1 from
Watson et al © 2022 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

The final expert panel consisted of 26 clinicians from 4 countries (19 of them from Canada, same as the majority of co-authors) and 10 clinical disciplines (including general internal medicine, endocrinology, cardiology, and nephrology) were able to reach a consensus on 42 specific recommendations. Let’s take a closer look at the 3 main questions of interest:

1) What symptoms or signs of acute illness should trigger SDMG?

The experts reached a consensus on 5 recommendations regarding signs and symptoms of volume depletion that should trigger SDMG, including vomiting or diarrhea leading to significant fluid loss, anorexia or nausea leading to a significant decrease in fluid intake, new dizziness, decreased weight, and decreased urine output. In addition, another 6 signs should prompt urgent contact with providers, including reduced level of consciousness, severe vomiting, low blood pressure, presence of ketones, tachycardia, and fever.

2) What should be included in SDMG?

The experts reached a consensus on recommendations for patient self-management VS. seeking assistance from a health care provider VS. emergency/urgent care with 14 different scenarios and strategies, including frequent glucose monitoring, checking ketones, fluid intake, and ensuring food consumption. For example, they recommended contacting health care providers when patients feel they are not coping; their symptoms have not resolved within 3 days; they cannot keep up with food/fluid intakes; they are experiencing recurrent low glucose readings or significant increase in glucose after 1 day of adjusting medications.

3) What medication instructions should be included in SDMG?

Medications such as renin-angiotensin-aldosterone system (RAAS) inhibitors, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), sodium-glucose cotransporter-2 (SGLT2) inhibitors and metformin were recommended to be held temporarily. Insulin, sulfonylureas and meglitinides were recommended to be held only when glucose levels were low. Furthermore, they made 6 recommendations regarding the resumption of these medications within 1-2 days of symptom resolution and return of normal eating/drinking patterns.

The current clinical practice of SDMG varies among medical providers. Even among the 26 experts included in the panel, only 9 of them provided SDMG frequently to their patients. Those who did not follow such practice cited a lack of evidence supporting SDMG as one of the major reasons. To add more complexity, even patients with high health literacy are often confused by the ambiguity of the SDMG recommendations offered by their medical providers. Another practical challenge is to ensure patients restart these potentially life-saving medications once the acute illness is over.

The authors should be applauded for undertaking a crucial step to achieve consensus on these SDMG clinical recommendations. Many research questions remain to be answered on SDMG. This study provides the foundation for future investigations aiming to evaluate whether SDMG interventions work in clinical settings. In parallel, the recommendations can also be used as a helpful resource of reference for clinicians caring for patients with cardio-renal-metabolic diseases.

– Post prepared by Mengyao Tang @tammyyaotang

To view Watson et al [OPEN ACCESS], please visit AJKD.org.

Title: Consensus Recommendations for Sick Day Medication Guidance for People With Diabetes, Kidney, or Cardiovascular Disease: A Modified Delphi Process
Authors: Kaitlyn E. Watson, Kirnvir Dhaliwal, Sandra Robertshaw, Nancy Verdin, Eleanor Benterud, Nicole Lamont, Kelsea M. Drall, Kerry McBrien, Maoliosa Donald, Ross T. Tsuyuki, David J.T. Campbell, Neesh Pannu, Matthew T. James on behalf of the PAUSE (Preventing Medication Complications During Acute Illness Through Symptom Evaluation and Sick Day Guidance) Medication Safety Advisory Panel
DOI: https://doi.org/10.1053/j.ajkd.2022.10.012