Research indicates that the care of inpatients with hyperglycemia and diabetes has improved significantly in the past decade. However, few studies have assessed the optimal management of these patients after hospital discharge. Currently, most patients admitted with uncontrolled diabetes are discharged home on their preadmission medications or no therapy.
Testing an Algorithm
Recently, the Endocrine Society released inpatient guidelines for the management of patients with diabetes. These guidelines include an algorithm with which to base post-discharge care, but recommendations are based solely on expert consensus. Accordingly, Guillermo Umpierrez, MD, and colleagues conducted an exploratory study to test the safety and efficacy of this algorithm, based on admission A1C levels. Participants included general medicine and surgical patients aged 18 to 80 with type 2 diabetes who were treated with insulin therapy in the hospital.
“For the study, patients with an A1C at admission of 7% or less were discharged home with the same medications they were on prior to admission,” explains Dr. Umpierrez. “Unfortunately, most people admitted to the hospital have an A1C between 8% and 9%. Patients with an A1C of 7% to 9% restarted their preadmission oral agents and received basal insulin at 50% of their in-hospital daily dose. Those with an A1C higher than 9% were discharged on oral agents plus 80% of the basal insulin dose they received in the hospital.” The primary outcome of the study was A1C change at 12 weeks after discharge.
The average A1C among participants decreased from 8.7% at baseline to 7.3% at 12 weeks after discharge, according to the results. Patients discharged on basal insulin were able to avoid the standard regimen of four shots per day. “We found that restarting any oral agents and prescribing half the dose of basal insulin used in the hospital once a day correlated with good glucose control for the majority of patients after discharge,” Dr. Umpierrez explains. The authors also found hypoglycemia in:
- 22% of patients discharged on oral agents alone.
- 25% on insulin alone.
- 30% on oral agents plus insulin.
- 44% on basal bolus.
“These cases were mostly mild,” says Dr. Umpierrez, “but the percentages are higher than what we’d like to see. We’re currently investigating the best way to prevent hypoglycemia at discharge.”
With no clear guidelines on the post-discharge care of patients with type 2 diabetes, Dr. Umpierrez urges physicians to consider the regimen used in the study to help achieve glucose control at home. He also stresses the importance of educating patients on hypoglycemia risk and assuring that they have contact with their primary provider soon after they are discharged.