How to safely initiate and discontinue diabetic (Diabetes Mellitus) therapy?

From the Guidelines

Safely stopping and starting diabetic therapy requires careful planning and medical supervision, with the primary goal of preventing hypoglycemia and managing hyperglycemia, as outlined in the most recent guidelines 1. To achieve this, several key considerations must be taken into account, including the patient's current health status, the type of diabetes they have, and their previous treatment regimen.

• For a stable patient, continuing with their previous regimen while focusing on preventing hypoglycemia and managing hyperglycemia through blood glucose monitoring is recommended 1.
• In patients with organ failure, preventing hypoglycemia is of greatest significance, and for those with type 1 diabetes, insulin administration may be reduced but not stopped, while for type 2 diabetes, agents that may cause hypoglycemia should be reduced in dose 1.
• For a dying patient, discontinuing all medications may be reasonable for type 2 diabetes, but for type 1 diabetes, a small amount of basal insulin may be maintained to prevent acute hyperglycemic complications 1. When temporarily stopping diabetes medications, it is crucial to work with a doctor to develop a specific plan that includes gradually reducing insulin doses, monitoring blood glucose more frequently, and having a clear threshold for when to resume medication, typically when blood glucose exceeds 180-200 mg/dL. Upon restarting therapy, beginning with lower doses than previously used, especially for insulin, and gradually increasing based on blood glucose readings is advised, with the option to start oral medications like metformin at half the previous dose and increase over 1-2 weeks 1. This cautious approach is necessary to avoid dangerous blood sugar fluctuations, including severe hypoglycemia or hyperglycemia, and to account for potential changes in insulin sensitivity during the break in treatment. Always keeping fast-acting glucose sources available when adjusting diabetes medications is also essential for patient safety. Given the most recent and highest quality study available 1, these recommendations prioritize morbidity, mortality, and quality of life as outcomes, ensuring the safest and most effective management of diabetic therapy.

From the FDA Drug Label

1. 4 Discontinuation for Iodinated Contrast Imaging Procedures Discontinue metformin hydrochloride tablets at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/min/1. 73 m 2; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure; restart metformin hydrochloride tablets if renal function is stable.

To stop and start diabetic therapy with metformin safely:

• Discontinue metformin hydrochloride tablets at the time of, or prior to, an iodinated contrast imaging procedure in patients with certain conditions, such as an eGFR between 30 and 60 mL/min/1.73 m^2, history of liver disease, alcoholism, or heart failure.
• Re-evaluate eGFR 48 hours after the imaging procedure.
• Restart metformin hydrochloride tablets if renal function is stable 2.

Note: The provided drug labels do not give explicit instructions for stopping and starting metformin in all situations, so caution should be exercised and healthcare provider guidance should be sought.

From the Research

Stopping Diabetic Therapy

• When stopping diabetic therapy, it is essential to consider the patient's individual characteristics and the mechanism of action of the drug being discontinued 3.
• Metformin should be discontinued if cardiac, hepatic, or renal failure develops 4.
• In patients with type 2 diabetes treated with insulin plus metformin, glycaemic control can be maintained after discontinuation of metformin by increasing the daily dose of insulin substantially (20 to 36%) during application of an intensified treatment protocol 4.

Starting Diabetic Therapy

• When starting insulin therapy in patients with type 2 diabetes, an individualized approach is necessary, taking into account the patient's specific needs and characteristics 5.
• The choice of glucose-lowering medicine for patients with type 2 diabetes should be based on an assessment of the patient's characteristics and understanding the mechanism of action for each drug 3.
• Metformin is the first choice of glucose-lowering medicine for most patients with type 2 diabetes, while sulphonylureas have proven benefits in long-term trials 3.

Adjusting Diabetic Therapy

• If a patient's HbA1c levels do not improve or show a limited response to a recently introduced medication, the initial agent should be continued with another therapy added, rather than switching or stopping the medication 6.
• Adding a new therapy to the existing treatment regimen can result in a substantially better reduction in HbA1c levels compared to switching or continuing the same medication 6.
• Oral antidiabetic agents differ in their mechanisms of action, efficacy, safety, and tolerability, and the choice of agent should be based on the individual patient's needs and characteristics 7.