Intensifying Diabetes Medication Regimen at Hospital Discharge May Not Benefit Older Patients

Among older individuals hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events, according to the results of a national cohort study. Findings were published in JAMA Network Open.

At 1 year, medication intensifications were also not associated with a reduction in severe hyperglycemic events or glycated hemoglobin (A_1C) levels.

“Modification of older adults’ home medications during short-term hospitalization is common,” authors wrote, while “during hospitalization for acute illness, older adults with diabetes may experience fluctuating blood glucose control, driven by changes in eating patterns, medication exposures, and catecholamine surges.”

In addition, the posthospitalization period is often a high-risk time for medication errors, they added. To better understand the clinical outcomes associated with diabetes medication intensification made at hospital discharge, researchers assessed those hospitalized in the national Veterans Health Administration (VHA) health system for common noncardiac conditions.

Specifically, postdischarge outcomes evaluated included severe hypoglycemia and hyperglycemia events, mortality, A_1C control after 1 year, and persistent use of discharge medications 1 year post discharge.

A total of 5296 individuals were included in the propensity-matched cohort. All individuals were aged 65 and older and were hospitalized between January 2011 and September 2016. Participants had a mean age of 73.7 while the majority were male (98.4%) and White (78.1%).

Although all individuals had diabetes upon admission, the cohort was split into those who received medication intensification at discharge and those who did not. “Intensifications were defined as newly prescribed diabetes medications that were not 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 researchers explained.

Patients were assessed 30- and 365-days post discharge.

Analyses revealed:

• Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (HR, 2.17; 95% CI, 1.10-4.28), 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)
• At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death, and no difference in change in A_1C level was found among those who did vs did not receive intensifications (mean postdischarge A_1C, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, −0.12% to 0.16%)
• At 1 year, 48% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled

“Despite the lack of association with improved diabetes control, older adults receiving diabetes medication intensifications at discharge had a lower risk of mortality at 30 days but no difference in mortality at 1 year,” the authors wrote. “These results suggest intensification of older adults’ outpatient diabetes medications during unrelated hospitalizations should generally be avoided.”

Of note, most older adults discharged with intensifications received new insulin or sulfonylureas, which are associated with a higher risk of hypoglycemia compared with other drug classes. More research is needed evaluating the real-world outcomes of novel classes such as sodium glucose co-transporter 2 inhibitors and glucagon-like peptide-1 agonists in this population.

For most older adults with well-controlled or modestly elevated A_1C levels, the researchers recommended deferring decisions to intensify treatment to outpatient clinicians.

Findings may not be generalization to the whole US population or to younger populations, marking a limitation to the study.

“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,” the authors concluded.

Reference

Anderson TS, Lee AK, King B, et al. Intensification of diabetes medications at hospital discharge and clinical outcomes in older adults in the veterans administration health system. JAMA Netw Open. Published online October 21, 2021. doi:10.1001/jamanetworkopen.2021.28998