Myocardial Infarction, Blood Sugar, and Diabetes: Treatment After Discharge

Medication omission at discharge is the most common type of medication discrepancy.

Patients who are hospitalized on one drug regimen are often discharged on an entirely different set of medications. Medication additions, deletions, or modifications are usually necessary to address the precipitating event and fine-tune the patient’s medications, because treating new conditions creates new potential drug interactions. However, several studies indicate that medication omission at discharge—simply forgetting to include medication(s)— is the most common type of medication discrepancy.^1,2

Medications associated with endocrine conditions are among the most frequently omitted.¹ People with diabetes and/or who have a myocardial infarction (MI) are at risk for 3 reasons. First, patients who experience an MI often have an elevated blood glucose level, regardless of whether they had been diagnosed with diabetes before the MI. They may continue to have an elevated blood glucose level after the MI, and may receive a diagnosis of diabetes. Second, patients with diabetes are at elevated risk for cardiovascular disease. Third, research has found that approximately 12% of patients with diabetes admitted to a hospital for MI were discharged without antihyperglycemic therapy (AHT). This increased the 1-year mortality rate in untreated patients.³

We need to heighten awareness of the need to resume or continue AHT after MI.

Holding AHT in the Hospital: It’s Reasonable

Clinical guidelines frequently recommend holding AHT (especially oral agents) during hospitalization, as insulin therapy is preferred.⁴ In lieu of oral therapy, the American Diabetes Association (ADA) recommends⁵:

• Scheduled subcutaneous insulin with basal, nutritional, and correction components to achieve or maintain glucose control (with no specific blood glucose goals) in noncritically ill inpatients
• Intravenous insulin for hyperglycemia exceeding 180 mg/dL, with a blood glucose goal of 140 to 180 mg/dL in critically ill inpatients
• More stringent goals (eg, 110 to 140 mg/dL) may be appropriate for select patients if these goals can be achieved without significant hypoglycemia

Although there are other legitimate reasons for discontinuing AHT (Table 1⁵), it’s often difficult to determine why medications are held or discontinued. A recent study found that in 327 records of patients whose AHT had been discontinued during hospitalization, 96% contained no explanation.⁶ Patients also tend to be discharged without standard cardiovascular therapies (aspirin, beta-blockers, 3-hydroxy-3-methylglutaryl- CoA reductase inhibitor) following acute MI. This indicates poor overall discharge planning, not just poor diabetes care. Clinicians shouldn’t assume that patients will continue their AHT after discharge, or that health care professionals involved in outpatient follow-up will handle AHT.

The Insulin-MI Conundrum

There is wide variation in the way hospitals approach hyperglycemia after MI.⁷ Pharmacists should note that, despite recommendations in most clinical guidelines to treat hyperglycemia in MI patients, clinicians have been hesitant to implement intensive glucose control because clinical trials have reported conflicting results. Observational studies indicate that hyperglycemia is common and increases mortality and complications. These studies show that tighter glucose control improves outcomes in hospitalized MI patients.^8-14

More structured clinical trials examining targeted glucose control among MI patients have had recruitment and methodological problems, and have yielded conflicting results.^15-17Further, a large recent study compared aggressive glucose control with more conservative control, finding that patients in the aggressive treatment arm were at greater risk for death.¹⁸ It’s confusing. Regardless, patients whose diabetes predates their MI will most likely receive insulin during hospitalization and will need continuing AHT at discharge.

Once MI patients who have received insulin are stabilized and are able to eat regularly, the hospital team should consider reinstituting oral and injectable noninsulin therapies. It’s also appropriate to restart them in anticipation of discharge. The ADA cautions that clinicians should start metformin only if the patient has no evidence of renal insufficiency, an unstable hemodynamic status, or a need for an imaging study that requires a radiocontrast dye.⁵

At Discharge: Pay Attention

It’s difficult to know if AHT is discontinued because prescribers forget to restart it or decide it’s not needed. To reduce mortality, good data support continuing AHT in older patients who have had a recent acute MI.³ Although the question of whether long-term glycemic control prevents future cardiovascular events is unanswered, the effects of hyperglycemia are generally believed to be more pronounced in patients who are older, have a longer duration of diabetes, or have comorbidities.⁵ The Agency for Healthcare Research and Quality has made recommendations concerning discharge (Online Table 2¹⁹).

Table 2: Agency for Healthcare Research and Quality Hospital Discharge Recommendations

Complete all of the following before patients are discharged:

· Medication reconciliation: Perform a crosscheck to ensure that (1) no long-term but still necessary medications were stopped inadvertently and (2) new prescriptions will be safe in the outpatient setting and with the patient’s other medications.

· Give patients and their caretakers the opportunity to fill and review new or changed medications before discharge.

· Provide accurate, structured discharge communication to each patient’s health care providers regarding medication changes, pending tests and studies, and follow-up needs.

· Transmit discharge summaries to the patient’s primary physician as soon as possible after discharge.

· Schedule outpatient medical follow-up appointments with primary care providers, endocrinologists, and diabetes educators, which improve appointment-keeping behavior and medical outcomes.

Adapted from reference 19.

In the Ambulatory Setting

Ambulatory care pharmacists can help at care transitions. The simple act of asking patients about recent hospitalizations and reviewing their medications with them can help identify gaps and omissions. Educating patients about their medications and their disease also helps. Increasingly, ambulatory care pharmacies are offering medication therapy management, and helping their pharmacists expand their expertise in diabetes and cardiac care. As pharmacists move toward recognition as providers, they will need to improve their documentation skills and act assertively when they see medication problems.²⁰

Virginia Bartok is a pharmacist whose primary practice was in indigent care. She currently provides case management for several geriatric patients, and reports many medication reconciliation problems after hospital discharge

References:

1. Herrero-Herrero JI, Garcia-Aparicolo J. Medication discrepancies at discharge from an internal medicine service. Eur J Intern Med. 2011;22:43-48.

2. Grimes TC, Duggan CA, Delaney TP, et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011;71:449-457.

3. Lipska KJ, Wang Y, Kosiborod M, et al. Discontinuation of antihyperglycemic therapy and clinical outcomes after acute myocardial infarction in older patients with diabetes. Circulation: Cardiovascular Quality and Outcomes. 2010;3:236-242.

4. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009; 32:1119-1131.

5. American Diabetes Association. Standard of medical care in diabetes—2013. Diabetes Care. 2013;34:S11—S66.

6. Lovig KO, Horwitz L, Lipska K, Kosiborod M, Krumholz HM, Inzucchi SE. Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error? Jt Comm J Qual Patient Saf. 2012;38:403-407.

7. Venkitachalam L, McGuire DK, Gosch K, et al. Temporal trends and hospital variation in the management of severe hyperglycemia among patients with acute myocardial infarction in the United States. Am Heart J. 2013;166:315-324.

8. Oswald G, Corcoran S, Yudkin J. Prevalence and risks of hyperglycaemia and undiagnosed diabetes in patients with acute myocardial infarction. Lancet. 1984;323:1264-1267.

9. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000;355:773-778.

10. Wahab NN, Cowden EA, Pearce NJ, et al. Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol. 2002;40:1748-1754.

11. Kosiborod M, Rathore SS, Inzucchi SE, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation. 2005;111:3078-3086.

12. Wong VW, Ross DL, Park K, et al. Hyperglycemia: still an important predictor of adverse outcomes following AMI in the reperfusion era. Diabetes Res Clin Pract. 2004;64:85-91.

13. Goyal A, Mahaffey KW, Garg J, et al. Prognostic significance of the change in glucose level in the first 24 h after acute myocardial infarction: results from the CARDINAL study. Eur Heart J. 2006;27:1289-1297.

14. Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation. 2008;117:1018-1027.

15. Malmberg K, Rydén L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57-65.

16. Malmberg K, Ryden L, Wedel H, et al. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J. 2005;26:650-661.

17. Cheung NW, Wong VW, McLean M. The hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) study. Diabetes Care. 2006;29:765-770.

18. The NICE-Sugar Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.

19. Agency for Healthcare Research and Quality. Adverse events after hospital discharge. http://psnet.ahrq.gov/primer.aspx?primerID=11. Accessed August 21, 2014.

20. Helling DK, Johnson SG. Defining and advancing ambulatory care pharmacy practice: it is time to lengthen our stride. Am J Health Syst Pharm. 2014;71:1348-1356.