medwireNews: Older adults with type 2 diabetes often receive diabetes medication adjustments at hospital discharge that may be of little or no benefit, study results suggest.
Timothy Anderson (Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA) and co-researchers studied 16,178 older adults (average age 73 years) with type 2 diabetes who were admitted to hospital with common medical conditions including heart failure, pneumonia, and coronary heart disease.
They report in JAMA Network Open that one in 10 of these people were discharged with intensified diabetes medication, defined as an additional medication or at least a 20% dose increase of a pre-existing one.
Of note, the majority (8% of the cohort) of these patients had intensification of medications that carry a high risk for hypoglycemia. Five percent had an insulin added (the study was limited to patients not using it before admission) and 3% had a sulfonylurea either added or the dose increased.
However, the team calculated that 49% of patients with medication intensifications were unlikely to benefit from them, because their preadmission glycated hemoglobin was relatively well controlled (<7.5%; 58 mmol/mol) and/or their estimated life expectancy was less than 5 years, based on age and Charlson Comorbidity Index score.
A further 20% were classified as likely to benefit and 31% as receiving intermediate benefit from medication intensification. The corresponding rates for those receiving intensification of medications with a high hypoglycemia risk were 45%, 23%, and 31%.
Having poor glucose control in the year before hospital admission was associated with an increased likelihood of receiving medication intensification, as was having high inpatient glucose levels; the highest rate of intensification, of just over 40%, was seen in people with both these characteristics.
However, 30% of dose intensifications occurred in people who had good glycemic control measured in the year before admission.
The author of a linked commentary, Eduard Vasilevskis (Vanderbilt University Medical Center, Nashville, Tennessee, USA), says it is “possible and even probable that inpatient clinicians unnecessarily intensify diabetes treatments at discharge.”
But he also believes the findings partly reflect hospital physicians attempting to extrapolate from the existing guidelines covering inpatient and outpatient glucose control, which are “silent regarding the role or method for adjusting preexisting diabetes medication regimens, especially in the context of ongoing inpatient hyperglycemia.”
Vasilevskis therefore highlights the “urgent need for randomized clinical trials to determine whether and how to intensify diabetes treatment regimens during an acute care transition period.”
He says: “New attention to this critical transition from the hospital to home or to postacute care will hopefully give new directions to inpatient clinicians to make improved patient-centered diabetes treatment decisions.”
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JAMA Netw Open 2020; 3: e201511
JAMA Netw Open 2020; 3: e201500