Anne L. Peters, MD, CDE; Kathleen M. Dungan, MD


June 28, 2013

Transitioning Back to Oral Agents After Discharge

Dr. Peters: That is a fascinating study and I hope it holds true, because it makes some sense and you obviously want to have as low a readmission rate as possible in patients who are discharged. Before I let you go, I want to ask you a question that I am asked all the time: What about the use of oral agents in hospitalized patients? Do you use oral agents in inpatients or do you stop the oral agents? Do you have an approach to using oral agents in the inpatient setting?

Dr. Dungan: We definitely stop the oral agents and all noninsulin therapies in the hospital. That is consistent with the current guidelines from the American Diabetes Association, the American College of Endocrinology, and the Endocrine Society. A lot more research needs to be done to investigate the appropriate use of oral agents in the hospital and the appropriate use of insulin in the hospital. We don't have enough data to support one way or another. In some cases, agents that don't cause hypoglycemia, or those that cause renal insufficiency or problems in patients with renal insufficiency, might be of use.

Dr. Peters: I am always confused when I see patients who have been in the hospital, and my patients are confused too when they have been discharged on insulin and not restarted on whatever agents they were taking before being admitted to the hospital. They are then sent back to me for follow-up. I can't quite figure out whether the patient should stay on insulin. When do you recommend restarting the oral agents? How do you recommend addressing this transition issue?

Dr. Dungan: That is an important question, one that has been raised but is not adequately answered by the current guidelines. It is important to obtain a hemoglobin A1c right when the patient is admitted to make sure that you are not dealing with potential confounders such as a red blood cell transfusion. Use that to guide your discharge treatment options. If the hemoglobin A1c is controlled and there are no new contraindications to therapy, then the patient can be restarted on their home regimen.

The exception might be a patient who is undergoing major cardiac surgery for which that stress response may persist for a longer period of time, or for someone who is discharged on corticosteroids, for which additional coverage may be necessary. The use of other agents in the hospital and how to transition patients back to their home regimens, when appropriate, need further evaluation.

Dr. Peters: Yes, that is an issue that I run up against all the time.


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