If the patient is readmitted, should we restart the medication?

Yes, restart the medication upon readmission unless an absolute contraindication has developed.

If the patient is readmitted, you should restart the previously discontinued medication, particularly if it was a guideline-directed medical therapy (GDMT) for conditions like heart failure. The evidence strongly supports that even when medications are stopped—whether due to clinical deterioration, side effects, or other reasons—they should be reinitiated once the patient is stabilized, as long as no absolute contraindication exists 1.

Key Principles for Medication Restart

Document Why It Was Stopped Initially

• Before restarting, review why the medication was discontinued during the previous admission
• If it was stopped due to a relative contraindication or intolerance (not an absolute contraindication), the medication should be restarted 1
• Common reasons for discontinuation that should NOT prevent restart include: temporary hemodynamic instability, mild side effects, or patient preference without medical justification

Beta-Blockers as the Prototype Example

The 2022 AHA/ACC/HFSA guidelines provide the clearest framework for this decision-making:

• Beta-blockers in HFrEF should be restarted even if previously discontinued, provided no absolute contraindication exists 1
• These medications reduce mortality and hospitalization risk regardless of symptom improvement 1
• The guideline explicitly states: "If a contraindication or intolerance are noted, they should be documented, and the patient restarted on beta-blocker therapy in the future, so long as an absolute contraindication is not present" 1
• Abrupt withdrawal leads to clinical deterioration—this is precisely why readmissions occur 1

Timing of Restart

• Medications can be safely initiated before hospital discharge if the patient is clinically stabilized 1
• Do not wait for symptoms to return or disease progression to be documented before restarting 1
• Start at low doses and uptitrate as tolerated, following the same principles as initial therapy 1

Common Pitfalls to Avoid

The "Medication Discontinuation Cascade"

Research shows that approximately 16% of deprescribed medications are restarted within 90 days, with nearly half occurring soon after facility discharge 2. This suggests:

• Care fragmentation during transitions increases inappropriate discontinuation
• Higher baseline medication burden and multiple prescribers increase restart likelihood 2
• Poor communication between hospital and outpatient teams perpetuates the cycle

The False Assumption of "Improvement"

• Even if symptoms or ejection fraction improve, long-term treatment must be maintained to prevent progression and major cardiovascular events 1
• Stopping GDMT because "the patient is doing better" is a critical error that leads to readmission

Monitoring Requirements Upon Restart

For medications like MRAs (mineralocorticoid receptor antagonists):

• Check potassium and renal function approximately 1 week, then 4 weeks, then regularly after restart 1
• Discontinue only if potassium cannot be maintained <5.5 mEq/L to avoid life-threatening hyperkalemia 1
• Adjust doses for renal function (eGFR 31-49 mL/min/1.73 m²: reduce dose by half) 1

Practical Algorithm for Readmission

1. Review medication list from prior admission - identify what was stopped and why
2. Assess for absolute contraindications - if none exist, plan to restart
3. Stabilize the patient clinically - ensure not requiring inotropic support or other acute interventions 1
4. Restart at appropriate doses - often lower than previous, with planned uptitration
5. Arrange close follow-up - within 1 week for high-risk medications requiring monitoring 1
6. Document the plan clearly - prevent future inappropriate discontinuation

Special Considerations

Patient-Specific Factors

Younger patients, males, and those with either very high or very low socioeconomic status have higher medication restart rates after discontinuation 3, suggesting these populations need enhanced transitional care support 2.

Substance Abuse and Health Literacy

Poor health literacy and substance abuse are major contributors to non-adherence and readmission 4. Address these barriers proactively:

• Provide simplified medication education
• Arrange substance abuse treatment referrals
• Consider long-acting formulations when available

The default position should always be to restart evidence-based medications upon readmission unless a documented absolute contraindication exists. The burden of proof lies in justifying why NOT to restart, not the other way around.