Diabetic Medicine Intensification May Not Benefit Older Adults After Hospitalization

Timothy S. Anderson, MD

Recently, a retrospective cohort study evaluated the associations between intensification of home diabetes medications at hospital discharge and outcomes at post discharge in older adults with diabetes hospitalized in the national Veterans Health Administration (VHA) health system.

Led by Timothy S. Anderson, MD, MAS, Division of General Medicine, Beth Israel Deaconess Medical Center, the team found that discharge with intensified diabetes medication was associated with increased short-term risk of severe hypoglycemia events, without a reduction of severe hyperglycemia events or improved HbA1c control.

What were the methods?

Investigators collected national inpatient and outpatient VHA pharmacy and clinical data merged with VHA and Medicare claims data from 2009 - 2018. Data analysis was thus performed from January 2020 - March 2021.

It consisted of adults with diabetes ≥65 years old, admitted to a VHA hospital between January 2011 - September 2016 for common medical conditions. In general, diabetes was defined by the presence of 2 outpatient diagnoses or any hospital discharge of diabetes in the preceding 2 years.

For specificity, investigators examined only patients taking a diabetes medication before hospitalization or who had a HbA1c level greater than 6.5% in the year before hospitalization. Additionally, they limited inclusion to patients not using insulin before hospitalization.

A comparison of patients discharged with an intensified diabetes medication regimen to those discharged without intensification was made. The study defined an intensification as a fill of prescription at hospital discharge for a new or higher-dose medication that was being used before hospitalization.

Further, propensity scores helped to construct a matched cohort of patients who did and did not receive diabetes medication intensification.

The primary outcomes in the study consisted of severe hyperglycemia and severe hypoglycemia events following medication intensification. They were thus examined at 30 days to assess immediate outcomes and at 365 days to assess longer term outcomes.

What did they find?

Out of 28,198 older adults with diabetes admitted to 115 VHA hospitals, a total of 2768 (9.8%) received medication intensification at discharge.

Then, the propensity-matched cohort included 5296 older adults with diabetes, with a mean age of 73.7 years who were 98.4% male (n = 5212). An equal split was made between patients who received medication intensification at discharge to those who did not receive medication intensification, at 2648 patients each.

Data show that within 30 days, patients who received medication intensification had a higher risk of severe hypoglycemia (HR 2.17; 95% CI, 1.10 - 4.28). On the other hand, 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) was observed.

At 365 days following discharge, no differences were seen in the risk of severe hyperglycemia, severe hypoglycemia, or death.

Further, little to no difference in change in HbA1c level among patients who did versus did not receive intensification was observed (mean postdischarge HbA1c: 7.72% versus 7.70%; 95% CI, -0.12% to 0.16%).

The team noted that at 1 year, 48.0% (591 of 1231) of new oral medications and 38.5% (548 of 1423) of new insulin medications were no longer filled, in comparison to 23.6% (4858 of 20,550) of same-dose continuations.

What were the takeaways?

“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,” investigators wrote.

The study, “Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System,” was published in JAMA Network Open.