The Challenges of Diabetes Medication Management at Hospital Discharge in Older Adults

The American Diabetes Association (ADA) provides guidance to clinicians for the care of older adults with diabetes.¹ The guideline suggests that healthy older adults have lower glycemic targets (such as a hemoglobin A_1c [HbA_1c] level of 7.5% of total hemoglobin [to convert to proportion of total hemoglobin, multiply by 0.01]), whereas older adults with multiple coexisting chronic illnesses, cognitive impairment, or functional decline should have less restrictive goals (such as an HbA_1c level of 8.0%-8.5%).

The ADA similarly provides evidence-based guidance for inpatient treatment of adults who are not critically ill.² Concerning glycemic targets, the guideline recommends initiation of insulin therapy for the treatment of persistent hyperglycemia starting at a threshold glucose level of 180 mg/dL (to convert to millimoles per liter, multiply by 0.0555) and a subsequent glucose level target range of 140 mg/dL to 180 mg/dL for most patients. Furthermore, the guideline recommends achieving these targets with a basal insulin regimen plus a correction or prandial dosing for individuals with regular dietary intake. Importantly, the ADA does not base inpatient guidance on age or comorbidity burden.

Each practice guideline provides a tool for clinicians managing one of the most common comorbid conditions to co-occur with diabetes. The challenge for the inpatient clinician occurs at the intersection of the 2 guidelines: the transition from acute care to the home or a postacute care setting. During acute care transitions, the evidence and guidelines are silent regarding the role or method for adjusting preexisting diabetes medication regimens, especially in the context of ongoing inpatient hyperglycemia.

In the absence of clear evidence, the study by Anderson et al³ describes inpatient clinician prescribing behaviors at hospital discharge for patients who experienced inpatient hyperglycemia as well as for patients admitted with an elevated HbA_1c level. The study found that among more than 16 000 older (ie, age ≥65 years) veterans with diabetes who were not previously on insulin, 10% experienced medication intensification (ie, a new diabetes medication or >20% increase the dose of a preexisting diabetes medication) at the time of discharge. Importantly, most intensifications included higher-risk medications (eg, insulin or sulfonylureas). Anderson et al³ estimated that only 20% of patients who received intensifications were likely to benefit from intensification, ie, their most recent HbA_1c levels were 9% or lower regardless of life expectancy. Alternatively, they estimated that 49% of patients who received intensifications were unlikely to benefit. These patients had an HbA_1c level less than 7.5% or had an HbA_1c level less than 9.0% with an estimated life expectancy of fewer than 5 years. Anderson et al³ estimated that the remaining 31% of patients receiving medication intensification experienced indeterminate benefit. This last group had HbA_1c levels between 7.5% and 9.0% with a life expectancy of 5 or more years.

Importantly, although Anderson et al³ provide labels of benefit to the intensification categories, these labels are based on the expected treatment response when following the ADA guidelines for older adults¹ for a patient seen in the outpatient setting. Extrapolating benefit categories to the period of hospital discharge, although intuitive, lacks the same level of evidence found in the ADA guidelines. In the absence of clear evidence at the time of transition, the study by Anderson et al³ demonstrates that inpatient clinicians may be responding to outpatient guidelines. For example, a major independent risk factor associated with medication intensification at discharge was an HbA_1c level greater than 9.0% (odds ratio, 7.06 [95% CI, 5.01-9.94]).³ This suggests an attempt by inpatient clinicians to alter the course of a measure that reflects outpatient glucose control. Similarly, inpatient clinicians may be extrapolating inpatient treatment guidelines to the postdischarge period. The study by Anderson et al³ found that the strongest intensification risk factor was the presence of severely elevated glucose during hospitalization (odds ratio, 9.46 [95% CI, 7.11-12.59]), supporting the possibility of an effort to continue control of hyperglycemia in the postdischarge period.

Reconciling 2 guidelines at the point of discharge is unlikely to be the only reason that patients receive intensification at the time of hospital discharge. First, patients at hospital discharge often continue to experience ongoing inflammation, stress, dietary modifications, and treatments (eg, corticosteroids) that may be associated with ongoing hyperglycemia after discharge and potentially warrant medication intensification. Second, clinicians are sensitive to inpatient and outpatient diabetes quality measures. Attempts to meet quality targets may limit the consideration of the entire patient context when making intensification decisions. Third, patients, caregivers, or receiving postacute care facilities may be uncomfortable with ongoing hyperglycemia and prefer medication intensification. Fourth, inpatient clinicians commonly work within interdisciplinary teams and often make discharge decisions at the recommendation of endocrinology or glucose management team members. Although many hospitals have increased the use of glucose management teams, few of them have guidelines surrounding medication intensification at hospital discharge.⁴

One can debate the cutoffs of labeling the appropriateness of medication intensification; however, there are some previously established areas of caution for inpatient clinicians. For example, a 2018 study from the US Department of Veterans Affairs reported increased risk of postdischarge hypoglycemia among patients recovering from acute kidney injury, regardless of their HbA_1c levels.⁵ Another study from the Department of Veterans Affairs suggested that when measured the day before discharge, decreasing glucose levels, particularly less than 100 mg/dL, were associated with increased risk of readmission and mortality.⁶ Importantly, in the study by Anderson et al,³ the patients with the lowest risk for intensification in this study were those with euglycemia, especially with well-controlled HbA_1c levels.

The evidence for discharge treatment decisions for older patients with ongoing hyperglycemia is incomplete. Considering the research by Anderson et al,³ it is possible and even probable that inpatient clinicians unnecessarily intensify diabetes treatments at discharge.³ Inpatient clinicians are appropriately concerned about outcomes among their patients with elevated HbA_1c levels and ongoing hyperglycemia. However, preventing potentially unnecessary intensification will require new evidence and continued improvements during care transitions.

This study by Anderson et al³ highlights some of the evidence and processes needed to improve discharge treatment decision-making. First, there is an urgent need for randomized clinical trials to determine whether and how to intensify diabetes treatment regimens during an acute care transition period. Second, for older patients, the best intervention may not be intensification but deprescribing. The median number of medications for this cohort was 9, with one-fourth of patients having 12 or more medications.³ Ongoing hospital-based research may help determine the safety of deprescribing diabetes medications, especially among older patients and those with HbA_1c levels less than 8.0% to 8.5%.⁷ Third, if a clinician decides to intensify medications, measures should be taken to avoid high-risk medications when possible (eg, insulin and sulfonylureas). Fourth, given the inability to accurately predict future glycemic control, continued innovations are needed in diabetes education, follow-up, and postdischarge monitoring (eg, continuous glucose monitoring, telehealth).

For many medical conditions, clinicians have been advised to treat the patient and not the numbers. However, this statement is much easier to say when backed by clear evidence. Anderson et al³ highlight that inpatient clinicians may be currently too focused on the numbers. Alternatively, inpatient clinicians may be responding to evidence that has been lost in transition. 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.

Published: March 24, 2020. doi:10.1001/jamanetworkopen.2020.1500

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Vasilevskis EE. JAMA Network Open.

Corresponding Author: Eduard E. Vasilevskis, MD, MPH, Department of Medicine, Division of General Internal Medicine, Section of Hospital Medicine, Center for Quality Aging, Vanderbilt University Medical Center, 2525 West End Ave, Ste 450, Nashville, TN 37203 (ed.vasilevskis@vumc.org).

Conflict of Interest: Dr Vasilevskis reported receiving grants from the National Institutes of Health, National Institute on Aging, and Vanderbilt Institute for Clinical and Translational Research.