Should hospital medication recommendations continue the same treatment?

Hospital Medication Recommendations Should Continue Pre-Admission Treatment

In the majority of hospitalized patients, medications prescribed for chronic conditions should be continued during hospitalization unless there are specific contraindications, hemodynamic instability, or documented treatment failure. This principle applies across multiple disease states and represents the standard of care supported by major medical societies.

Core Principle: Medication Continuity as Default

• Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction should be continued during hospitalization unless contraindications exist or hemodynamic instability is present 1.
• For patients with non-ST-elevation acute coronary syndromes, medications required to control ischemia in the hospital should be continued after discharge in patients who do not undergo revascularization, have unsuccessful revascularization, or develop recurrent symptoms 1.
• In psychiatric hospitalizations, resuming baseline psychiatric medications is standard practice unless there is clear evidence of harm, ineffectiveness, or compelling reason to modify the regimen 2.
• Discontinuing effective medications during short inpatient stays may result in unexpected and unmonitored return of symptoms after discharge, particularly problematic with brief hospital stays 2.

Disease-Specific Guidance

Heart Failure

• Beta-blockers and ACE inhibitors/ARBs should be continued in most patients with heart failure during hospitalization 1.
• Withholding or reducing beta-blocker therapy should only be considered in patients hospitalized after recent initiation/uptitration, marked volume overload, or marginal/low cardiac output 1.
• Patients with significant worsening of renal function should be considered for temporary reduction or discontinuation of ACE inhibitors, ARBs, and/or aldosterone antagonists until renal function improves 1.
• Pre-existing GDMT should be continued and optimized during hospitalization to improve outcomes 1.
• If discontinuation of GDMT is necessary during hospitalization, it should be reinitiated and optimized as soon as possible 1.

Diabetes Management

• For older adults in skilled nursing facilities receiving short-term rehabilitation, if the treatment regimen increased in complexity during hospitalization, it is reasonable to reinstate the prehospitalization medication regimen 1.
• However, insulin is the preferred treatment for hyperglycemia in most hospitalized patients, and oral glucose-lowering medications should typically be discontinued during acute hospitalization 3, 4.
• Oral agents should be reinitiated 1-2 days before discharge if they were part of the home regimen and the patient is clinically stable and eating well 3, 4.

Psychiatric Medications

• Avoid abrupt discontinuation of antipsychotics to prevent rebound worsening of symptoms 2.
• Lithium requires particular caution with abrupt discontinuation due to risk of rebound mania 2.
• Long-acting injectable antipsychotics should be continued as they represent a valuable tool for preventing relapse 2.
• Benzodiazepines prescribed chronically should be continued, but gradual tapering is essential if discontinuation is planned to avoid withdrawal symptoms 2.

When to Modify or Discontinue Pre-Admission Medications

Absolute Contraindications

• Documented severe or recurrent adverse effects with the previous regimen (significant weight gain, movement disorders, dangerous side effects) 2.
• Acute medical contraindications such as QTc prolongation with antipsychotics, uncontrolled hypertension with stimulants, or significant drug-drug interactions 2.
• Clear evidence of treatment failure or lack of symptom control on current regimen 2.
• Hemodynamic instability or cardiogenic shock 1.

Temporary Modifications

• Metformin should be suspended in patients with risk of lactic acidosis (sepsis, hypoxia, significant renal insufficiency, hepatic insufficiency) 4.
• During acute illness with unpredictable oral intake or NPO status, oral diabetes agents require more flexible management than they can provide 3.
• Patients with marked volume overload or recent beta-blocker uptitration may require temporary dose reduction 1.

Common Pitfalls to Avoid

• Do not automatically discontinue all home medications simply because the patient is hospitalized - this increases risk of symptom relapse and complicates discharge planning 2.
• Research demonstrates that 50% of chronic medications are changed during hospitalization, with 28-36% cancelled, often unnecessarily 5, 6.
• Hospital-specific drug formularies and preferences should not drive unnecessary medication changes when patients are stable on their current regimen 6.
• Avoid starting multiple new medications simultaneously without first assessing response to the home regimen, as this complicates attribution of therapeutic effects and adverse events 2.
• Do not delay restarting medications while awaiting complete evaluation if the patient has been stable on their current regimen - continuation provides a baseline for assessment 2.

Evidence of Harm from Unnecessary Changes

• In observational studies, only 13 of 300 hospitalized patients (4.3%) experienced no change to their drug regimen during hospitalization 5.
• More than 60% of patients had 3 or more changes made to their drug regimen, with many changes affecting medications for diseases unrelated to the hospitalization 5.
• The rate of drug cancellation for antihypertensive and cardiac drugs did not differ between patients hospitalized for cardiovascular versus non-cardiovascular problems, suggesting non-selective discontinuation 5.
• Discontinuation of beta-blockers during heart failure hospitalization is associated with higher mortality risk compared to continuation 1.

Discharge Planning and Communication

• Before hospital discharge, patients should receive well-understood instructions regarding medication type, purpose, dose, frequency, and side effects 1.
• Hospital discharge letters often fail to provide detailed information about drug changes - only 5 of 130 discharge letters in one study documented reasons for medication changes 6.
• Ensure clear documentation of which medications were intentionally discontinued versus which should be resumed after acute illness resolves 7.
• Medications intended only for acute illness complications (antipsychotics for delirium, stress ulcer prophylaxis, acute bronchodilators) are frequently continued unintentionally after discharge, accounting for significant unnecessary costs and potential harm 7.