How to switch a patient from insulin therapy in a hospital setting to Oral Hypoglycemic Agents (OHAs) at home?

Transitioning from Hospital Insulin to Oral Hypoglycemic Agents at Home

For Type 2 diabetes patients previously on oral agents alone who required insulin during hospitalization, resume their previous oral medications at the same doses after 48 hours if HbA1c is <8% and renal function is adequate (creatinine clearance >30 mL/min for all OHAs, >60 mL/min for metformin), while progressively decreasing and stopping ultra-rapid insulin as glycemic control is achieved. 1

Decision Algorithm Based on HbA1c and Pre-Hospital Treatment

For T2D Patients Previously on OHAs Only

The transition strategy depends critically on the HbA1c level obtained during hospitalization:

HbA1c <8% 1

• Resume previous oral medications at the same doses after 48 hours if renal function is adequate 1
• Start ultra-rapid insulin initially, then decrease doses progressively until it can be stopped 1
• Arrange follow-up with treating physician within 1-2 weeks to discuss potential OHA dose increases if needed based on the patient's individualized HbA1c target 1
• Ensure home nursing support is arranged for initial glucose monitoring 1

HbA1c 8-9% 1

• Resume OHAs at the same doses if no contraindications exist 1
• Stop ultra-rapid insulin 1
• Continue slow-acting insulin (e.g., glargine/Lantus) at home 1
• Patient is discharged on their usual OHAs plus one injection of slow-acting insulin 1
• Provide a protocol for insulin dose adaptation 1
• Schedule distant consultation with a diabetologist 1

HbA1c >9% or Persistent Hyperglycemia (>11 mmol/L or 200 mg/dL) 1

• Do NOT transition to OHAs alone 1
• Maintain the basal-bolus insulin scheme 1
• Request diabetologist consultation before discharge for possible hospitalization in specialized service 1

For T2D Patients Previously on OHAs Plus Insulin

HbA1c <8% 1

• Resume previous treatment at the same doses as during hospitalization 1
• Consultation with treating physician advisable within 1-2 weeks 1

HbA1c 8-9% 1

• Resume previous treatment 1
• Request consultation with diabetologist for therapy intensification 1

HbA1c >9% or Poor Control 1

• Maintain basal-bolus scheme 1

Critical Renal Function Considerations

Before resuming any oral agents, verify renal function: 1

• Creatinine clearance must be >30 mL/min for all OHAs 1
• Creatinine clearance must be >60 mL/min specifically for metformin 1

This is essential because metformin carries risk of lactic acidosis in renal impairment, and other OHAs require dose adjustment or discontinuation with reduced kidney function.

Stress Hyperglycemia (Non-Diabetic Patients)

For patients with stress hyperglycemia characterized by elevated blood glucose but HbA1c <6.5%: 1

• Stop insulin progressively as capillary blood glucose normalizes 1
• No treatment necessary at discharge 1
• Critical caveat: 60% of these patients will develop diabetes within one year 1
• Measure fasting blood glucose at one month, then annually 1
• Monitor systematically in all future stress situations 1

Practical Discharge Recommendations

Medication Timing 1

• If oral medications were suspended during hospitalization, resume them 1-2 days before discharge 1
• This allows assessment of glycemic response before the patient leaves the hospital

For Patients with Poor Prior Control (HbA1c >10%) 2, 3

• Discharge on either a basal-bolus insulin regimen OR 2
• Previous oral agents plus 80% of the hospital basal insulin dose 2, 3
• Do not attempt transition to OHAs alone in this population

Patient Education Requirements 1

Provide comprehensive diabetes self-management education including:

• Understanding of diabetes diagnosis and meaning of hyperglycemia/hypoglycemia 1
• Self-monitoring of blood glucose technique 1
• Blood glucose targets 1
• Dietary advice 1
• Injection technique if continuing any insulin 1
• Sick-day management 1

Common Pitfalls to Avoid

Never abruptly discontinue insulin without ensuring adequate oral agent coverage - this risks rebound hyperglycemia, particularly with sulfonylureas that have long half-lives and may take several days to reach steady-state effectiveness 4

Do not resume metformin in patients with: 1

• Sepsis or active infection
• Hypoxia
• Significant renal insufficiency (CrCl <60 mL/min)
• Hepatic insufficiency
• Any risk factors for lactic acidosis

Avoid transitioning patients with HbA1c >9% to OHAs alone - these patients have demonstrated inadequate control and require continued insulin therapy 1

Monitor for hypoglycemia during transition - particularly when resuming sulfonylureas or glinides, as these insulin secretagogues can cause delayed hypoglycemia when overlapping with residual insulin effect 1

Follow-Up Schedule

• HbA1c <8%: Treating physician at 1 month 1
• HbA1c 8-9%: Diabetologist consultation (can be distant/telemedicine) 1
• HbA1c >9%: Diabetologist consultation before discharge 1