Can oral medications be continued in a patient with type 2 diabetes?

Continuation of Oral Medications in Type 2 Diabetes Patients

Oral medications should be continued in patients with type 2 diabetes during hospitalization unless there are specific contraindications, with appropriate monitoring and potential adjustments based on clinical status. 1

Assessment of Oral Medications in Hospitalized Patients

• Metformin should be continued as the preferred first-line pharmacologic agent for type 2 diabetes as long as it is tolerated and not contraindicated 1
• The medication regimen should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed based on specific factors that impact treatment choice 1
• For hospitalized patients with type 2 diabetes, continuing home oral glucose-lowering medications may be appropriate in certain circumstances 1

When to Continue Oral Medications

• Patients with acceptable diabetes control (HbA1c <7.5-8%) can be discharged on their prehospitalization treatment regimen (oral agents and/or insulin) 1
• Dipeptidyl peptidase 4 inhibitors (DPP-4i) alone or in combination with basal insulin represent an effective and safe alternative to basal-bolus insulin regimens for hospitalized patients with mild to moderate hyperglycemia 1
• Once treatment goals are met, the frequency of blood glucose monitoring can be decreased for patients on oral agents with low hypoglycemia risk 1

When to Modify or Discontinue Oral Medications

• Metformin should be discontinued in patients at risk for lactic acidosis, such as those with anaerobic metabolism (sepsis, hypoxia), impaired metformin clearance (significant renal impairment), or impaired lactic acid clearance (liver failure) 1
• Sulfonylureas should be discontinued first when patients experience hypoglycemia, especially when they are already on other effective glucose-lowering agents 2
• For patients with HbA1c between 8.0% and 10%, consider discharging on oral agents plus basal insulin at 50% of the hospital basal dose 1

Specific Recommendations by Medication Class

Metformin

• Continue unless contraindicated; reduce dose if eGFR is 30-45 mL/min/1.73m² and discontinue if eGFR is less than 30 mL/min/1.73m² 1
• Discontinue before iodinated contrast procedures in patients with reduced eGFR (<60 mL/min/1.73m²), history of liver disease, alcoholism, or acute heart failure 1

Sulfonylureas

• Higher risk of hypoglycemia compared to other oral agents; consider discontinuing first if hypoglycemia occurs 2
• Not recommended in premixed formulations in the hospital setting due to high risk of iatrogenic hypoglycemia 1

DPP-4 Inhibitors

• Can be safely continued in hospitalized patients, including in combination with basal insulin 1, 3
• Linagliptin has shown efficacy when used in combination with insulin, with statistically significant improvements in A1C compared to placebo 3

SGLT2 Inhibitors

• For patients with established atherosclerotic cardiovascular disease, kidney disease, or heart failure, SGLT2 inhibitors with demonstrated cardiovascular benefit should be continued as part of the glucose-lowering regimen 1

Monitoring Recommendations

• For patients on oral agents with good metabolic control, an infrequent or intermittent monitoring schedule may be adequate 1
• More frequent monitoring should be advised during times of illness or if symptoms of hyperglycemia or hypoglycemia develop 1
• For patients on oral agents plus a single injection of long-acting insulin, twice-daily blood glucose monitoring (fasting plus a second post-prandial measurement) is often recommended 1

Common Pitfalls to Avoid

• Using premixed insulin therapy (human insulin 70/30) in hospitalized patients has been associated with an unacceptably high rate of iatrogenic hypoglycemia 1
• Sole use of correction or supplemental insulin without basal insulin (formerly referred to as sliding scale) in the inpatient setting is discouraged 1
• Discontinuing all oral medications automatically upon hospital admission without individual assessment may lead to suboptimal glycemic control 1

By following these evidence-based guidelines, clinicians can safely continue appropriate oral medications for patients with type 2 diabetes during hospitalization, potentially improving glycemic control while reducing the risk of hypoglycemia and readmission.