Stepping Up Diabetes Drug Regimen After Hospital Discharge May Not Benefit Older Patients



The results of a retrospective study showed no benefit in older patients whose diabetes medications were stepped up after short hospital stays.

According to the results of a national cohort study, in elderly people hospitalized with common medical problems, discharge with intensified anti-diabetic drugs was associated with a short-term increased risk of severe hypoglycemia events. The results were published in JAMA network open.

At 1 year, drug intensifications were also not associated with a reduction in severe hyperglycemic events or glycated hemoglobin (A1 C) levels.

“Changing home medications for older people during acute hospital stays is common,” the authors wrote, while “during acute hospitalization, older people with diabetes may experience fluctuations in blood pressure. blood sugar control, brought about by changes in eating habits, exposure to drugs and spikes in catecholamines.

In addition, the post-hospitalization period is often a high risk period for medication errors, they added. To better understand the clinical outcomes associated with stepping up diabetes medication upon discharge, researchers assessed people hospitalized in the Veterans Health Administration’s (VHA) National Health System for non-heart conditions. current.

Specifically, the post-discharge outcomes assessed included severe hypoglycemia and hyperglycemia events, mortality, A1 C control after 1 year and persistent drug use on discharge 1 year after discharge.

A total of 5296 individuals were included in the propensity matched cohort. All of the people were aged 65 and over and were hospitalized between January 2011 and September 2016. Participants had an average age of 73.7 years, while the majority were men (98.4%) and whites ( 78.1%).

Although all individuals had diabetes on admission, the cohort was divided into those who received intensified medication on discharge and those who did not. “Intensifications were defined as newly prescribed diabetes drugs that were not used prior to hospitalization and drugs present on admission for which an discharge order was filled for a dose increase of more than 20. % “, the researchers explained.

Patients were assessed 30 and 365 days after discharge.

The analyzes revealed:

  • Within 30 days, patients who received drug 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 to 3.08), and a lower risk of death (RR: 0.55; 95% CI: 0.33-0.92)
  • At 1 year, no difference was found in the risk of severe hypoglycaemic events, severe hyperglycaemic events, or death, and no difference in the change in A1 C level was found among those who did vs did not receive intensifications (average after exit A1 C, 7.72% against 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 dispensed on discharge were no longer filled

“Despite the lack of association with better diabetes control, older people receiving intensifications of anti-diabetic drugs at discharge had a lower risk of 30-day mortality but no difference in 1-year mortality,” wrote the authors. “These results suggest that escalation of ambulatory diabetes medication in the elderly during unrelated hospitalizations should generally be avoided.”

Of note, most older people who were discharged with intensifications received new insulin or sulfonylureas, which are associated with a higher risk of hypoglycemia compared to other classes of drugs. Further research is needed to assess actual results from new classes such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 agonists in this population.

For most older people with well-controlled or slightly elevated A1 C levels, the researchers recommended deferring the decision to scale up treatment to outpatient clinicians.

The results may not be generalized to the entire U.S. population or to younger populations, marking a limit to the study.

“For most patients with elevated blood glucose levels in a hospital setting, communicating concerns about patient diabetes control to patients and their outpatient clinicians for close follow-up may be a safer route than stepping up medication. against diabetes on discharge “, concluded the authors.

Reference

Anderson TS, Lee AK, King B, et al. Scaling Up Diabetes Drugs on 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


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