COMMENTARY

3 Top Controversial Guidelines Directing Inpatient Care

Alok S. Patel, MD; Daniel D. Dressler, MD, MSc; Leonard S. Feldman, MD

Disclosures

July 08, 2019

Alok S. Patel, MD: Hi. I'm Dr Alok Patel with Medscape. I'm excited to be talking to Drs Dan Dressler and Lenny Feldman about controversial guidelines in internal and hospital medicine.

Gentlemen, thank you so much for talking to us. I'm excited to hear: What is controversial? What are the guidelines that get people fired up to talk about?

Inpatients With Diabetes─Give Them Subcutaneous Insulin or Oral Meds?

Daniel D. Dressler, MD, MSc: We're going to start off with diabetes guidelines.[1] How do we manage elevated blood sugars in the inpatient setting? Can we use oral hypoglycemics, which have been the standard for the past decade? Do we have to switch everyone off their orals, put them on sub-cu insulin, and stick them throughout their hospital stay? Can we use orals in the hospital?

Leonard S. Feldman, MD: Or can you use a sub-cu GLP-1 receptor agonist (eg, exenatide) or DPP-4 inhibitors? These are the newer drugs that everyone is excited about but that we always stop when a patient comes in to the hospital.

Patel: Do you feel that people belong to "team sub-cu insulin" or "team oral hypoglycemics" out there?

Dressler: I would say the people supporting oral hypoglycemics in the United States comprise a very small subset. It just happens that, in my institution, I work with individuals who have been studying this. I'm on the side of being able to consider and use oral hypoglycemics in the hospital.

Patel: Persuasive. I like it.

Feldman: For the purpose of the debate that we're having here, Dan is for using the new medications (the DPP-4 inhibitors and the GLP-1 receptor agonists) and I am against it.

I am in support of going with the old, tried-and-true insulin and not trying any of these new-fangled medications on our patients in the hospital. We should use the medications that we know work. We know, from most of the studies that have been done by the folks that Dan works with, that insulin works well in the hospital.

Transfusions─What Are the Thresholds?

Patel: I may have to separate you two! What's another controversial guideline that you have been covering?

Dressler: The next controversial guideline is related to transfusions and transfusion thresholds.[2]

Patel: This is something that every hospitalist deals with all the time.

Feldman: Many of us agree now that we can transfuse patients when their hemoglobin level is less than 7 g/dL if they are healthy (eg, not having an MI, no coronary artery disease).

The real controversy comes in regarding when to transfuse a patient who has coronary artery disease and a hemoglobin level of 7.5 or 7.8 g/dL. Do we need to transfuse these patients or can we let them ride?

Dressler: This really becomes more uncertain when you have someone who may not be having an actual heart attack but who is known to have heart disease. Some guidelines suggest that they need to be transfused at a hemoglobin level of 8 g/dL or below versus other data suggesting that we can transfuse at 7 g/dL or below.

That's our debate. We see a lot of patients who end up at 7.8 or 7.2 g/dL. What should we do? This is another area, again, where Dr Feldman and I are going to debate. I'm going to suggest that I'm better with lower thresholds...

Feldman: ...and I'm going to say he's trying to kill people.

Syncope—Do We Need the Echo?

Patel: There's going to be fire in this room! What's the third controversial guideline that's being debated?

Feldman: The final guideline that we're looking at is an American College of Cardiology/American Heart Association/Heart Rhythm Society guideline on syncope and whether we need to get an echocardiogram (echo) for a patient with syncope who doesn't have the usual kind of concern for structural heart disease.[3] In other words, should we just be getting the echo on most of our patients who have syncope?

Patel: And, the other side?

Dressler: Lenny's a little bit concerned because every participant at this meeting who's met him has passed out. [Laughter] He's ready to order echoes for everybody!

The issue is cost. Many of our hospitalists may not even realize why an echo costs between $1500 and $2500. It's not like an EKG that's probably $50 to $100 or less. Echoes are expensive studies. Being a minimalist, not everyone really needs an echo. Going by the guidelines, you really want to think about what, based on a patient's history or physical exam, makes me need to go that route. If I choose to order an echo, it needs to be supported.

Patel: Gentlemen, thanks so much for chatting with us.

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