medwireNews: Intensification of diabetes medications in older adults at the point of discharge from hospital is associated with an increased risk for hypoglycemia, without gains in glycemic control, research suggests.
“For most older adults with well-controlled or modestly elevated HbA1c [glycated hemoglobin] levels, deferring decisions to intensify treatment to outpatient clinicians is likely the safest course,” write the researchers in JAMA Network Open.
They explain that “this practice avoids the tendency to treat elevated inpatient blood glucose values, which are typically transitory, with a change to long-term therapy that may result in increased risk of severe hypoglycemia.”
However, the team points out that the study used data from 2011 to 2016, predating widespread use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors.
The majority of medication intensifications therefore involved sulfonylureas or insulin, which carry an increased risk for hypoglycemia relative to the newer medication classes, without their cardioprotective benefits.
Writing in a linked commentary, Rozalina McCoy (Mayo Clinic, Rochester, Minnesota, USA) and Patrick O’Connor (HealthPartners Institute, Minneapolis, Minnesota) say that “the world has changed a lot since 2016.”
They write: “Initiation of these [newer] medication classes in patients such as those in this study, of whom more than half had coronary artery disease and kidney disease and more than one-third had heart failure, may well have resulted in lower rates of hypoglycemia, hospitalizations, and deaths.”
In the study population of 28,198 people with diabetes, aged at least 65 years and admitted to Veterans Health Administration hospitals, 9.8% had their diabetes medications intensified at discharge; 2648 of these people (average age 73.7 years, 98.3% men) were propensity matched to an equal number who did not have their medications altered.
Severe hypoglycemia was rare during the first 30 days after discharge, but significantly more common in people with intensified medications than in those without, at 1.0% versus 0.5%.
During the following year, the average HbA1c level of people with medication intensification declined, from 7.91% to 7.72% (63 to 61 mmol/mol), but there was a near identical reduction in people without.
Of note, a third of the new diabetes prescriptions were never filled again and 16.4% were filled just once. Approximately 40–50% were no longer being filled 1 year later, compared with 23.6% of pre-existing prescriptions.
“This can reflect the fact that prescribed medications were not truly necessary but rather were prescribed for self-limited hyperglycemia or based on assumptions of poor glycemic control stemming from inpatient hyperglycemia and acute illness,” write McCoy and O’Connor in their commentary.
“These findings further underscore the need for better integration of hospital and ambulatory care, medication reconciliation and review during posthospital follow-up appointments, and comprehensive transitions-of-care programs.”
Timothy Anderson (Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA) and co-researchers did find an almost halved risk for 30-day mortality among people with medication intensification, but they believe the two are unlikely to have been causally linked given the short timeframe.
“Instead, clinicians may be appropriately identifying certain patients at high short-term risk of death and choosing not to intensify their diabetes medication regimens based on factors not captured by our propensity score,” they suggest.
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JAMA Netw Open 2021; 4: e2128998
JAMA Netw Open 2021; 4: e2130926