What home medications should a patient with Hyperosmolar Hyperglycemic State (HHS) and diabetes continue after hospital management?

Home Medications After HHS Management

Continue metformin and basal insulin at adjusted doses, while holding SGLT2 inhibitors, GLP-1 agonists, and sulfonylureas until the patient is stable and euvolemic. 1

Medications to Continue

Metformin

• Resume metformin once the patient is clinically stable, euvolemic, and renal function has normalized (creatinine returned to baseline, eGFR stable) 1, 2
• Metformin should be continued as the foundation of type 2 diabetes therapy unless contraindicated 1, 2
• Hold metformin if there is ongoing acute illness, dehydration, or renal impairment (eGFR <30 mL/min/1.73m²) due to lactic acidosis risk 3, 4

Basal Insulin

• Continue or initiate basal insulin (insulin glargine or detemir) as the cornerstone of glycemic management 1, 2
• For patients previously on insulin: reduce home dose by 20% if they were on high-dose insulin (≥0.6 units/kg/day) to prevent hypoglycemia 2, 4
• For insulin-naive patients: start at 10 units once daily or 0.1-0.2 units/kg/day 1, 2
• Basal insulin must never be held completely, even in patients with poor oral intake, as it provides essential background glucose control 1, 2

Antihypertensive Medications

• Resume ACE inhibitors, ARBs, and other antihypertensives once euvolemia is achieved and renal function is stable 1
• These medications should be continued in the absence of hemodynamic instability or contraindications 1

Statins

• Continue statin therapy throughout hospitalization and after discharge 1
• No dose adjustment is typically needed unless there are specific contraindications 1

Medications to Hold or Discontinue

SGLT2 Inhibitors

• Hold SGLT2 inhibitors during acute illness and for at least 3-7 days after HHS resolution 1, 5
• These agents increase risk of euglycemic DKA and volume depletion 5
• Can be cautiously restarted once the patient is stable, euvolemic, and eating normally 1

GLP-1 Receptor Agonists

• Hold GLP-1 agonists during acute illness due to gastrointestinal side effects (nausea, vomiting) that can worsen dehydration 1
• Resume once oral intake is adequate and the patient is clinically stable 1

Sulfonylureas

• Discontinue sulfonylureas permanently or hold until glycemic control is reassessed 1, 2
• These agents significantly increase hypoglycemia risk, especially when combined with insulin 1, 2
• If restarted, use with extreme caution and only after insulin doses are stabilized 2

Thiazolidinediones (TZDs)

• Hold TZDs during hospitalization due to fluid retention risk 1
• Reassess need for these agents at outpatient follow-up 1

Discharge Insulin Regimen

Basal-Bolus Approach for Severe Hyperglycemia

• For patients with HbA1c ≥9% or severe hyperglycemia during hospitalization, discharge on basal-bolus insulin at 80% of inpatient total daily dose 4
• Split as 50% basal insulin once daily and 50% prandial insulin divided among three meals 2, 4

Basal-Only Approach for Moderate Hyperglycemia

• For patients with HbA1c <9% and good glycemic control in hospital, discharge on basal insulin alone 1, 2
• Start at 10 units once daily or 0.1-0.2 units/kg/day 2
• Provide clear titration instructions: increase by 2 units every 3 days if fasting glucose >130 mg/dL 2

Critical Discharge Planning Elements

Medication Reconciliation

• Cross-check all medications to ensure no chronic medications were inappropriately stopped 1
• Provide written prescriptions for all new or changed medications before discharge 1
• Review medication costs and insurance coverage to ensure adherence 4

Patient Education Requirements

• Provide diabetes self-management education including glucose monitoring, insulin administration, hypoglycemia recognition and treatment, and sick day management 1, 4
• Teach proper insulin injection technique and site rotation 2
• Ensure patient has supplies: glucose meter, test strips, lancets, insulin syringes or pens 1

Follow-Up Scheduling

• Schedule outpatient follow-up within 1-2 weeks of discharge for patients with medication changes or suboptimal glucose control 1
• Earlier follow-up (within 1 week) is preferred for patients discharged on new insulin regimens 1
• Arrange endocrinology referral if not already established 1

Common Pitfalls to Avoid

• Never discharge patients on sliding scale insulin alone—this approach is ineffective and associated with poor outcomes 1, 3, 4
• Never discontinue metformin when starting insulin unless contraindicated—the combination provides superior control with less weight gain 2
• Never restart SGLT2 inhibitors immediately after HHS—wait until the patient is fully stable and euvolemic 5
• Never discharge without clear written instructions for insulin titration—therapeutic inertia leads to prolonged hyperglycemia 2
• Never assume patients can afford prescribed medications—discuss costs and alternatives before discharge 4