According to a study just published in JAMA Network Open, some older people with diabetes who are discharged from the hospital are prescribed higher doses of medications — and it’s not necessary.
The authors, who were led by Timothy S. Anderson, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, investigated records collected between 2011 and 2016 from more than 28,000 people with type 2 diabetes who had been admitted to a hospital in the Veterans Health Administration Health System for a variety of common medical problems — conditions like arrhythmia, asthma, chest pain, chronic obstructive pulmonary disease, coronary artery disease, heart failure, pneumonia, skin infection, stroke, and urinary tract infection (UTI). The authors chose these problems, as they put it, “because they are among the most common medical discharge diagnoses for older adults and their short-term management does not typically require intensification of outpatient diabetes medications.” Nearly all the patients were white and male, and the average age was 73. None were taking insulin, although most were using metformin or sulfonylureas, or both.
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Of the subjects, 2,768 were identified as having received higher doses of diabetes medications after discharge from the hospital. The authors defined intensified diabetes medications as “filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization and medications present on admission for which a discharge prescription was filled for a dose increase of more than 20%.” The authors noted that adjusting diabetes medications is common during hospitalization for illness because, as they put it “older adults with diabetes may experience fluctuating blood glucose control, driven by changes in eating patterns, medication exposures, and catecholamine surges,” which puts them at risk for “serious hypoglycemia [low blood sugar] and hyperglycemia events.”
The researchers first looked at the effect of the higher medication doses after a three-month period. They reported that the intensified regimen patients had a risk of episodes of severe hypoglycemia that was twice that of the other patients. The risk of high blood sugar was about the same in both groups, but, somewhat surprisingly, the intensified regimen patients’ risk of death was cut in half.
No advantage found of higher dose of medications
Next, the researchers took a look at how the subjects were doing after a year. This time, they reported that the patients who had the higher medication doses had rates of low blood sugar, high blood sugar, and death that were the same as the other patients. In addition, the researchers did not report any significant differences in HbA1c levels (a measure of long-term glucose control) between the two groups. In other words, there was no observable advantage from taking the higher dose of medications.
As a result, the authors wrote that “short-term hospitalization may not be an effective time to intervene in long-term diabetes management.” The episodes of high blood sugar some people experience are “typically transitory,” and, the researchers suggested, it might be better to put off any medication adjustments until patients have been discharged and are being seen in an “outpatient setting.” The authors noted that “most older adults discharged with intensified diabetes medications … received new insulin or sulfonylureas, which carry a higher risk of hypoglycemia than other diabetes medication classes.”
The published study was accompanied by a commentary by Rozalina G. McCoy, MD, of the Mayo Clinic and Patrick J. O’Connor, MD, of HealthPartners Institute in Minneapolis. They speculated that the reason for the lower death rate among intensified medication patients after three months might have to do with their being given a closer follow-up after leaving the hospital. Otherwise, their conclusions were similar to the authors’. “Intensification of glucose-lowering therapy upon hospital discharge does not appear to improve glycemic control but exposes patients to risk of preventable harm due to severe hypoglycemia in the immediate postdischarge period.”
Want to learn more about navigating a hospital stay with diabetes? Read “What to Expect in the Hospital.”