No Benefit to Intensifying Diabetes Meds at Hospital Discharge

Some older folks discharged from the hospital left with a more intense — and possibly unnecessary — treatment regimen for their diabetes, according to findings from the VA health system.

In a retrospective study of over 28,000 patients ages 65 and older with type 2 diabetes, about 11% were discharged with an intensified regimen, which seemed to yield a mixed bag of outcomes, as these patients had more than a two-fold higher risk of severe hypoglycemia within 30 days (HR 2.17, 95% CI 1.10-4.28), reported Timothy S. Anderson, MD, MAS, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, and colleagues.

However, risk of death was cut by nearly half within the 30 days after discharge for these patients versus those who left with the same treatment regimen (HR 0.55, 95% CI 0.33-0.92), the group wrote in JAMA Network Open.

There was no difference between the groups in the risk for severe hyperglycemia during the month following discharge (HR 1.00, 95% CI 0.33-3.08).

In an accompanying commentary, Rozalina G. McCoy, MD, MS, of the Mayo Clinic in Rochester, Minnesota, and Patrick J. O’Connor, MA, MD, MPH, of HealthPartners Institute in Minneapolis, offered one possible explanation for the unexpected 30-day mortality benefit for those who left with an intensified regimen, suggesting that this may be due to the fact that these patients had a closer follow-up in the outpatient setting, or may be due to improved glycemic control, leading to better recovery from illness, infection, and wound healing.

Nonetheless, the commentators said it is telling how few patients adhered to the newly prescribed medications, noting that this highlights the need for “better integration of hospital and ambulatory care.”

Fast forwarding to 1 year after hospital discharge, those who left with an intensified regimen saw no differences in the risks for severe hypoglycemia events, severe hyperglycemia events, or death compared with those who did not have their medications intensified. There also didn’t seem to be any significant difference in HbA1c level change between these groups (mean post-discharge HbA1c 7.72% vs 7.70%, difference-in-differences 0.02%, 95% CI -0.12% to 0.16%).

At this 1-year mark, 48% of new oral diabetes medications and nearly 40% of new insulin prescriptions given at discharge were no longer being filled.

“These results suggest intensification of older adults’ outpatient diabetes medications during unrelated hospitalizations should generally be avoided,” Anderson’s group wrote.

For the majority of older adults with either well-controlled or only “modestly” elevated HbA1c levels, it’s safest to defer decisions on intensifying regimens to outpatient clinicians, they added.

“[T]his practice avoids the tendency to treat elevated inpatient blood glucose values, which are typically transitory, with a change to long-term therapy that may result in increased risk of severe hypoglycemia,” they explained.

For this analysis, the group used inpatient and outpatient data from the Veterans Health Administration Health System from 2011 to 2016 for older adults with diabetes who were hospitalized for common medical conditions not related to diabetes. Nearly all were men, and 80% were white, with a mean age of 73.

At the time of hospital admission, most patients were on metformin and/or sulfonylureas. None were on insulin.

Prior to propensity score matching, the researchers drew upon data on 2,768 patients discharged with an intensified diabetes regimen and 25,430 with no such intensification. After matching, the cohort was comprised of 5,296 patients — half who received intensified regimens versus half who did not.

“Most older adults discharged with intensified diabetes medications in this study received new insulin or sulfonylureas, which carry a higher risk of hypoglycemia than other diabetes medication classes,” Anderson’s group noted.

“Novel classes, such as SGLT2 inhibitors and GLP-1 agonists, may have different benefit-harm profiles owing to lower hypoglycemia risks and strong cardioprotective benefits; thus, our study findings, which examined a period before the widespread use of these new classes, do not extend to these classes,” they explained.

McCoy and O’Connor agreed with the study authors, pointing out that the lack of SGLT2 inhibitors and/or GLP-1 receptor agonists as part of the intensified regimens was a major limitation.

“Initiation of these medication classes in patients such as those in this study, of whom more than half had coronary artery disease and kidney disease and more than one-third had heart failure, may well have resulted in lower rates of hypoglycemia, hospitalizations, and deaths,” they wrote.