MANAGEMENT OF ORAL ANTIHYPERGLYCEMIC MEDICATIONS … · 2020-06-01 · management of oral...
Transcript of MANAGEMENT OF ORAL ANTIHYPERGLYCEMIC MEDICATIONS … · 2020-06-01 · management of oral...
MANAGEMENT OF ORAL ANTIHYPERGLYCEMIC MEDICATIONS DURING GENERAL HOSPITAL ADMISSIONMEREDITH VIGNEAUX, PHARMD, ASHLEY EVANS, PHARMD, BCACP, CHARLES LUNDAY, PHARMD
CONFLICT OF INTEREST
The speaker has no actual or potential conflict of interest in relation to this presentation
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ABOUT MERCY
Founded by the Sisters of Mercy in 1891
Springfield, Missouri
886 bed hospital
Level 1 trauma, STEMI, and burn center
Part of an integrated health system with 173 clinics in the Springfield Community, 50 of those clinics being primary care
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LEARNING OBJECTIVE
Recognize the impact of continuation or discontinuation of home oral antihyperglycemic medications (OAM) on inpatient glycemic management.
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BACKGROUND
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This study investigated glycemic safety in relation to home OAM continuation or discontinuation.
The current practice at the study institution is to discontinue home OAM, unless reasonable to continue per clinician’s
judgement.
Hypoglycemia rates of 30-40% have been observed in patients continued on home OAM during hospital admission.3,5
Continuation of home oral antihyperglycemic medications (OAM) puts patients at increased risk for experiencing glycemic
events during hospital admission.
3.Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications5.Frequency and Severity of Hypoglycemia in Type 2 Diabetes Mellitus Patients Treated with a Sulfonylurea-Based Regimen at University-Affiliated Hospitals in Korea
PRIMARY OBJECTIVE
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Occurrence of composite glycemic events defined as:
Hyperglycemia is 2 blood glucose readings of >180 mg/dL1,2
Level 1 Hypoglycemia is 1 blood glucose of <70 mg/dL1
Level 2 Hypoglycemia is 1 blood glucose of <54 mg/dL1
Level 3 Hypoglycemia is 1 blood glucose of <40 mg/dL2
1. ADA Standards of Care 20202. Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study Investigators
SECONDARY OBJECTIVES
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Occurrence of hyperglycemia
Occurrence of hypoglycemia
Length of hospital stay (LOS)
• Hyperglycemic medications: sliding scale insulin (SSI)• Hypoglycemic medications: dextrose and glucagon
Use of glycemic medications
METHODS
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IRB approval on January 15th, 2020
125 patients in each group with a predicted glycemic event rate of 50% needed to achieve 90% power
Alpha was set at 0.05
Nieman Fisher test used for the primary objective
Retrospective chart review
INCLUSION CRITERIA9
OAM on home medication list Age ≥18 years
Admitted to study institution from
7/1/2017 to 7/1/2019
EXCLUSION CRITERIA
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Hypoglycemia upon
admission
Admission diagnosis of
DKA or HHS
Admitted for < 48 hours
Admission diagnosis of myocardial infarction
DKA = diabetic ketoacidosis, HHS = hyperosmolar hyperglycemic state
DATA STRATIFICATION
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OAM continued within the first 48 hours of admission
OAM discontinued upon admission
STUDY POPULATION
1000 patient charts reviewed
804 did not meet study criteria
196 met study criteria
69 patients were continued on home OAM
127 patients were discontinued on
home OAM
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BASELINE CHARACTERISTICS
Home OAM Average Age (years)
Male (%)
Female (%)
Average BMI (kg/m2)
Average A1C (%)
Average LOS (days)
SSI Use (%)
Continued 68.2 53.6 46.4 32.5 7.8 5.7 60.1
Discontinued 66.2 53.5 46.5 34.9 8.1 6 85.8
P -Value 0.15 0.31 0.31 0.045 0.24 0.28 0.0001
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PRIMARY OBJECTIVE
PRIMARY OBJECTIVE : COMPOSITE GLYCEMIC EVENTS
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Continued = 76.8%
Discontinued = 76.3%
P value = 0.95
Not statistically significant
SECONDARY OBJECTIVES
INPATIENT GLYCEMIC EVENTS STRATIFIED BY TYPE
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66.7
5.82.9 1.4
66.1
7.12.4 0.8
0
10
20
30
40
50
60
70
80
Hyperglycemia Level 1 Hypoglycemia Level 2 Hypoglycemia Level 3 Hypoglycmia
PERC
ENTA
GE
OF
GLY
CEM
IC E
VEN
TS
TYPE OF GLYCEMIC EVENT
Inpatient Glycemic Event
Continued Discontinued
p = 0.94
p = 0.73p = 0.82 p = 0.66
LENGTH OF STAY IN DAYS
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5.7
6
5.9
5.55 5.6 5.65 5.7 5.75 5.8 5.85 5.9 5.95 6 6.05
Continued
Discontinued
Total
Days
Length of Stay in Days
p = 0.28
USE OF RESCUE MEDICATIONS
2.9
0
2.4
00
0.5
1
1.5
2
2.5
3
3.5
Dextrose Glucagon
Perc
enta
ge o
f Use
Rescue Medications
Use of Rescue Medications
Continued Discontinued
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p = 0.82
LIMITATIONS 20
The study did not reach a priori power.
There may be a difference in glycemic event rates after continuation versus discontinuation of home OAM that was not evident in the study population.
01Under reporting of glycemic events due to inconsistent blood glucose monitoring during some admissions
02Continuous ongoing improvement of glycemic safety by study institution
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CONCLUSION
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Low rates of hypoglycemia seen in the study suggest the current practice surrounding continuation or discontinuation of home OAM at the study institution is safe.
Further investigation would help better define glycemic management best practices.
AREAS FOR FUTURE INVESTIGATION
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Role of pharmacist clinical judgment in continuation or discontinuation of home OAM at point of verification
Patient parameters associated with continuation or discontinuation of home OAM
Compliance with best practice alerts regarding glucose monitoring for safety
Impact of continuation or discontinuation of home OAM on the transitions of care process in relation to patient safety and adherence outcomes
Cost associated with SSI versus home OAM continuation
RESOURCES
1. American Diabetes Association-Standards of Medical Care in Diabetes 2020.
2. Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study Investigators. n engl j med 360;13 nejm.org march 26, 2009.
3. Lori M. Dickerson, PharmD,BCPS et al. Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications: A Multicenter Randomized Controlled Trial. Annals of Family Medicine Vol. 1, No. 1 May/June 2003.
4. Thomas G. K. Breuer and Juris J. Meier. Inpatient Treatment of Type 2 Diabetes. DeutschesÄrzteblatt International | Dtsch Arztebl Int 2012; 109(26): 466–74
5. Yon Su Kim et al. Frequency and Severity of Hypoglycemia in Type 2 Diabetes Mellitus Patients Treated with a Sulfonylurea-Based Regimen at University-Affiliated Hospitals in Korea: The Naturalistic Evaluation of Hypoglycemic Events in Diabetic Subjects Study. Korean J Fam Med. 2019 Jul;40(4):212-219. doi: 10.4082/kjfm.18.0051. Epub 2019 Jul 20.
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CONTACT INFORMATION
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Meredith Vigneaux, PharmD Mercy Hospital, Springfield, MO
Email: [email protected]
Phone: 417-820-4194
QUESTIONS
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