What note statement should I use to indicate the patient should continue glucose‑dependent medication therapy (Gdmt) without interruption?

Continue Guideline-Directed Medical Therapy (GDMT) Without Interruption

GDMT should be continued at the usual dose during acute intercurrent illness (e.g., pneumonia, COPD exacerbation, systemic infection) unless specific intolerances develop, and if temporarily withheld, must be restarted before discharge. 1

Documentation Statement for Your Note

Use this language:

"Continue all GDMT medications (ACEi/ARB/ARNI, beta-blocker, MRA, SGLT2i) at current doses during hospitalization. Do not discontinue GDMT unless life-threatening complications occur. If doses are reduced due to hemodynamic concerns, decrease by 50% rather than stopping completely, and uptitrate to previous tolerated dose as soon as safely possible. GDMT provides proven mortality and morbidity benefits and should not be interrupted by other clinicians without discussion with the managing team." 1, 2, 1

Key Principles for GDMT Continuation

When to Continue GDMT at Full Dose

• During acute intercurrent illness (pneumonia, infections, COPD exacerbations) unless not tolerated 1
• During hospitalization for any reason - the transition point provides opportunity for optimization, not discontinuation 3
• Even with "low" systolic blood pressure (80-100 mmHg) if patient is asymptomatic and tolerating therapy 2

Critical Pitfall to Avoid

Do not allow other clinicians to spontaneously discontinue GDMT without discussion with the managing team. 2 This is explicitly discouraged in guidelines because:

• Patients on GDMT have consistently better long-term outcomes than those who don't receive it 3
• Abrupt discontinuation can lead to rebound decompensation
• Postural symptoms early after discharge often lead to indiscriminate reduction of recommended therapies 3

When Dose Reduction (Not Discontinuation) Is Appropriate

If there is concern about GDMT tolerability:

• Decrease dose by one-half rather than stopping 1
• Reassess the patient on the reduced dose
• Uptitrate to previous tolerated dose as soon as safely possible 1

What to Adjust Instead of GDMT

Before reducing GDMT, carefully re-evaluate other concomitant drugs with less proven benefit (e.g., diuretics) to determine whether their dose can be reduced or discontinued 1

Specific Scenarios

For symptomatic hypotension with GDMT:

• Consider separating the timing of GDMT administration from other BP-lowering medications 1
• Reduce diuretic doses before reducing GDMT
• Check postural vital signs to confirm true hypotension vs. postural symptoms

For renal dysfunction:

• An increase in creatinine up to 30% is expected and acceptable when ACEi/ARB is introduced 1
• This does not require discontinuation if it stabilizes at 30%
• Closer long-term monitoring is appropriate

Only exception for abrupt discontinuation: Life-threatening complications only 1 - and even then, this should be a rare occurrence requiring explicit documentation of the life-threatening nature of the complication.

For Diabetes Medications (If "GDMT" Refers to Glucose-Dependent Medications)

If you're referring to diabetes medications rather than heart failure GDMT:

For SGLT2i and metformin during acute illness:

• Temporarily withhold SGLT2i during prolonged fasting, surgery, or critical illness (ketosis risk) 4, 5
• Continue SGLT2i even if eGFR falls below 30 once initiated, unless not tolerated 4
• Stop metformin if eGFR <30, but continue at adjusted doses for eGFR 30-44 4
• Resume within 24-48 hours of normal eating/drinking 5

During hospitalization:

• Oral antidiabetes drugs are typically stopped and replaced with insulin 6, 7
• However, continuation may be appropriate in selected stable patients 6
• Personal CGM and AID systems should be continued when clinically appropriate 7