Previously Well-Controlled Diabetes

The problem, they added, is when intensification of diabetes medication regimens occurs for patients with previously well-controlled diabetes. Those might “contribute to unnecessary polypharmacy and pose a risk of overtreatment. Both overtreatment and medication confusion may risk hypoglycemia, particularly when insulins and sulfonylureas are intensified,” the researchers wrote.

Medical conditions leading to hospitalization in the patients were asthma, chronic obstructive pulmonary disease, pneumonia, sepsis, skin infection and urinary tract infection. Cardiovascular conditions included arrhythmia, chest pain, coronary artery disease, acute coronary syndrome, conduction disorders, congestive heart failure, heart valve disorder, stroke and transient ischemic attack. Excluded were patients with secondary discharge diagnoses of diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome, which might necessitate an acute change in diabetes treatment.

The sample also was limited to patients who received at least 80% of their outpatient care in VHA settings and, therefore, were expected to regularly receive medications from VHA pharmacy sources.

Nearly 70% of patients in the study had been taking one or more diabetes medications prior to hospitalization, with metformin and sulfonylureas most commonly prescribed. In addition, more than one-quarter of patients had an estimated life expectancy of less than five years, with the most common discharge diagnoses being congestive heart failure (16%), pneumonia (12%), coronary artery disease (11%), conduction disorders (10%) and chronic obstructive pulmonary disease (10%).

Researchers list the most common drug intensifications as insulin additions, which occurred in 781 hospitalizations (5%). Intensifications of sulfonylureas occurred in 557 hospitalizations (3%), although some of those might have been therapeutic substitutions. Metformin intensification also was common, occurring in 382 hospitalizations (2%),.

“In the hospital setting, many factors may cause blood glucose levels to fluctuate,” the authors explained. “Patients may experience physiologic stress hyperglycemia related to acute illness, be given medications that raise blood glucose levels (e.g., corticosteroids or intravenous solutions containing dextrose), and have different dietary patterns than they would at home.”

In addition, they pointed out, both acute kidney injury and inability to take pills by mouth are common in hospitalized older adults and may lead inpatient clinicians to withhold outpatient diabetes medications. For this reason, temporary inpatient sliding scale insulin protocols have become common despite risks of hypoglycemia.

Yet, the study determined that one-third of patients with elevated inpatient blood glucose recordings had tightly controlled preadmission HbA1c, indicating that inpatient hyperglycemia is not a reliable marker to guide adjustments to outpatient diabetes regimens.

“Despite this, our findings indicate that inpatient blood glucose elevations frequently lead clinicians to intensify outpatient diabetes treatment, which may lead to unnecessarily intensive treatment,” researchers concluded.

  1. Anderson TS, Lee S, Jing B, et al. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open. 2020;3(3):e201511. doi:10.1001/jamanetworkopen.2020.1511