The practice of optimizing medications when older adults are discharged from the hospital often includes increasing the dosage of diabetic medications to compensate for hyperglycemic excursions that may result from other medical conditions. Research published online in October 2021 in JAMA Network Open warns prescribers to avoid diabetic-regimen intensification in cases such as this to avoid severe hypoglycemic events post discharge and that intensification does not add additional benefit in preventing severe hyperglycemia within a year.
Timothy S. Anderson, MD, from the Beth Israel Deaconess Medical Center in Boston, Division of General Medicine, and also affiliated with Harvard Medical School, Boston, Massachusetts, and San Francisco Veterans Affairs Medical Center, San Francisco, California, and colleagues set out to explore the potential association between clinical outcomes in older adults hospitalized for common medical conditions and intensification of medications prescribed upon hospital discharge. The researchers conducted a retrospective study that evaluated 5,296 patients aged 65 years and older with diabetes who were not taking insulin and who were hospitalized for common medical conditions at the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016. Data analysis was completed on March 31, 2021. The nondiabetic discharge diagnoses included, but were not limited to, common medical conditions such as pneumonia, skin infection, and heart failure.
The subjects' demographics included in the propensity-matched cohort were mean age 73.7 years; 98.4% male; and 78.1% white, 16.4% black, and 0.9% Hispanic. Subjects were equally divided among those who received and did not receive diabetes medication intensifications at hospital discharge. The results were measured at 30 days, with the patients who received intensification experiencing a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28).
After 1 year, however, no differences were found in the risk of severe hypoglycemia events. Other findings were no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08) and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92) for patients with intensification. When those who did receive intensification were compared with those who did not, there were no differences in severe hyperglycemia events or death and no difference in change in HbA1c values. Postdischarge mean differences in HbA1C were 7.72% versus 7.70%, respectively.
The team highlighted the importance of their findings as building on previous research and noted that their study was the first to evaluate outcomes of the intensification of diabetes medication upon discharge from the hospital, especially after hospitalization for other common medical conditions. It was their hope that their findings would provide data to inform prescribing practices for clinicians planning changes to diabetic medication when discharging patients.
Previous studies examined outcomes of patients discharged with concurrent medication regimen intensifications; however, those did not evaluate hypo- or hyperglycemic events. The researchers noted weaknesses including the absence of key covariates, such as laboratory values or vital signs. The authors concluded, "For most patients with elevated inpatient blood glucose levels, communication of concerns about patients' diabetes control to patients and their outpatient clinicians for close follow-up may provide a safer path than intensifying diabetes medications at discharge," further noting, "These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management."
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