To Hold or Not to Hold, That Is the Question: Sick Day Medication Guidance as Routine Care

With the demonstrated cardiovascular- and kidney-protective benefits of medications such as sodium/glucose cotransporter 2 inhibitors, renin-angiotensin-aldosterone system inhibitors, and mineralocorticoid receptor antagonists, there are increased rates of initiation and use of combinations of these agents. The same mechanisms that allow for the reduction of glomerular hypertension and blood pressure limit the ability to maintain kidney perfusion in the setting of volume depletion and relative hypotension and, as a result, increase the risk of development of acute kidney injury (AKI) and the severity of AKI. "Sick-day" medication guidance that provides recommendations for holding medications in the setting of illness to mitigate the risk of AKI has not been widely adopted by practitioners. Confusion regarding the criteria to define a sick day, lack of clarity as to how long to hold the medications and when to resume treatment, concerns that this information drives patient hesitancy to use the medications, lack of data demonstrating the benefit of holding medication, and concerns that patients will lose out on the therapeutic benefits of these agents as a result of constant interruption have fueled arguments against the regular use of these sick-day medication guidelines. In this perspective, sick-day medication guidance will be shown to be a valuable tool in counseling patients about the use of medications that reduces the risk of and costs associated with an AKI episode and ultimately promotes more consistent use of these important medications.