MANAGEMENT OF ORAL ANTIHYPERGLYCEMIC MEDICATIONS DURING GENERAL HOSPITAL ADMISSIONMEREDITH VIGNEAUX, PHARMD, ASHLEY EVANS, PHARMD, BCACP, CHARLES LUNDAY, PHARMD

CONFLICT OF INTEREST

The speaker has no actual or potential conflict of interest in relation to this presentation

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ABOUT MERCY

Founded by the Sisters of Mercy in 1891

Springfield, Missouri

886 bed hospital

Level 1 trauma, STEMI, and burn center

Part of an integrated health system with 173 clinics in the Springfield Community, 50 of those clinics being primary care

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LEARNING OBJECTIVE

Recognize the impact of continuation or discontinuation of home oral antihyperglycemic medications (OAM) on inpatient glycemic management.

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BACKGROUND

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This study investigated glycemic safety in relation to home OAM continuation or discontinuation.

The current practice at the study institution is to discontinue home OAM, unless reasonable to continue per clinician’s

judgement.

Hypoglycemia rates of 30-40% have been observed in patients continued on home OAM during hospital admission.3,5

Continuation of home oral antihyperglycemic medications (OAM) puts patients at increased risk for experiencing glycemic

events during hospital admission.

3.Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications5.Frequency and Severity of Hypoglycemia in Type 2 Diabetes Mellitus Patients Treated with a Sulfonylurea-Based Regimen at University-Affiliated Hospitals in Korea

PRIMARY OBJECTIVE

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Occurrence of composite glycemic events defined as:

Hyperglycemia is 2 blood glucose readings of >180 mg/dL1,2

Level 1 Hypoglycemia is 1 blood glucose of <70 mg/dL1

Level 2 Hypoglycemia is 1 blood glucose of <54 mg/dL1

Level 3 Hypoglycemia is 1 blood glucose of <40 mg/dL2

1. ADA Standards of Care 20202. Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study Investigators

SECONDARY OBJECTIVES

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Occurrence of hyperglycemia

Occurrence of hypoglycemia

Length of hospital stay (LOS)

• Hyperglycemic medications: sliding scale insulin (SSI)• Hypoglycemic medications: dextrose and glucagon

Use of glycemic medications

METHODS

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IRB approval on January 15th, 2020

125 patients in each group with a predicted glycemic event rate of 50% needed to achieve 90% power

Alpha was set at 0.05

Nieman Fisher test used for the primary objective

Retrospective chart review

INCLUSION CRITERIA9

OAM on home medication list Age ≥18 years

Admitted to study institution from

7/1/2017 to 7/1/2019

EXCLUSION CRITERIA

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Hypoglycemia upon

admission

Admission diagnosis of

DKA or HHS

Admitted for < 48 hours

Admission diagnosis of myocardial infarction

DKA = diabetic ketoacidosis, HHS = hyperosmolar hyperglycemic state

DATA STRATIFICATION

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OAM continued within the first 48 hours of admission

OAM discontinued upon admission

STUDY POPULATION

1000 patient charts reviewed

804 did not meet study criteria

196 met study criteria

69 patients were continued on home OAM

127 patients were discontinued on

home OAM

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BASELINE CHARACTERISTICS

Home OAM Average Age (years)

Male (%)

Female (%)

Average BMI (kg/m2)

Average A1C (%)

Average LOS (days)

SSI Use (%)

Continued 68.2 53.6 46.4 32.5 7.8 5.7 60.1

Discontinued 66.2 53.5 46.5 34.9 8.1 6 85.8

P -Value 0.15 0.31 0.31 0.045 0.24 0.28 0.0001

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PRIMARY OBJECTIVE

PRIMARY OBJECTIVE : COMPOSITE GLYCEMIC EVENTS

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Continued = 76.8%

Discontinued = 76.3%

P value = 0.95

Not statistically significant

SECONDARY OBJECTIVES

INPATIENT GLYCEMIC EVENTS STRATIFIED BY TYPE

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66.7

5.82.9 1.4

66.1

7.12.4 0.8

0

10

20

30

40

50

60

70

80

Hyperglycemia Level 1 Hypoglycemia Level 2 Hypoglycemia Level 3 Hypoglycmia

PERC

ENTA

GE

OF

GLY

CEM

IC E

VEN

TS

TYPE OF GLYCEMIC EVENT

Inpatient Glycemic Event

Continued Discontinued

p = 0.94

p = 0.73p = 0.82 p = 0.66

LENGTH OF STAY IN DAYS

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5.7

6

5.9

5.55 5.6 5.65 5.7 5.75 5.8 5.85 5.9 5.95 6 6.05

Continued

Discontinued

Total

Days

Length of Stay in Days

p = 0.28

USE OF RESCUE MEDICATIONS

2.9

0

2.4

00

0.5

1

1.5

2

2.5

3

3.5

Dextrose Glucagon

Perc

enta

ge o

f Use

Rescue Medications

Use of Rescue Medications

Continued Discontinued

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p = 0.82

LIMITATIONS 20

The study did not reach a priori power.

There may be a difference in glycemic event rates after continuation versus discontinuation of home OAM that was not evident in the study population.

01Under reporting of glycemic events due to inconsistent blood glucose monitoring during some admissions

02Continuous ongoing improvement of glycemic safety by study institution

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CONCLUSION

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Low rates of hypoglycemia seen in the study suggest the current practice surrounding continuation or discontinuation of home OAM at the study institution is safe.

Further investigation would help better define glycemic management best practices.

AREAS FOR FUTURE INVESTIGATION

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Role of pharmacist clinical judgment in continuation or discontinuation of home OAM at point of verification

Patient parameters associated with continuation or discontinuation of home OAM

Compliance with best practice alerts regarding glucose monitoring for safety

Impact of continuation or discontinuation of home OAM on the transitions of care process in relation to patient safety and adherence outcomes

Cost associated with SSI versus home OAM continuation

RESOURCES

1. American Diabetes Association-Standards of Medical Care in Diabetes 2020.

2. Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study Investigators. n engl j med 360;13 nejm.org march 26, 2009.

3. Lori M. Dickerson, PharmD,BCPS et al. Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications: A Multicenter Randomized Controlled Trial. Annals of Family Medicine Vol. 1, No. 1 May/June 2003.

4. Thomas G. K. Breuer and Juris J. Meier. Inpatient Treatment of Type 2 Diabetes. DeutschesÄrzteblatt International | Dtsch Arztebl Int 2012; 109(26): 466–74

5. Yon Su Kim et al. Frequency and Severity of Hypoglycemia in Type 2 Diabetes Mellitus Patients Treated with a Sulfonylurea-Based Regimen at University-Affiliated Hospitals in Korea: The Naturalistic Evaluation of Hypoglycemic Events in Diabetic Subjects Study. Korean J Fam Med. 2019 Jul;40(4):212-219. doi: 10.4082/kjfm.18.0051. Epub 2019 Jul 20.

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CONTACT INFORMATION

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Meredith Vigneaux, PharmD Mercy Hospital, Springfield, MO

Email: Meredith.Vigneaux2@Mercy.net

Phone: 417-820-4194

QUESTIONS

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