Transitioning from inpatient to outpatient therapy in patients with in-hospital hyperglycemia

Transition from inpatient to outpatient care for patients with type 2 diabetes mellitus is an important aspect of patient management for which there is no guidance. Intensive glucose lowering with insulin is generally favored for seriously ill hospitalized patients, but after discharge, patients often resume their prior regimens, which may include an array of oral or injected glucose-lowering agents. Factors that should be considered in this transition include goals of care/life expectancy, glycated hemoglobin at hospital admission, home medications for other illnesses and their potential for interactions with antidiabetes treatment, comorbidities, nutritional status, physical disabilities, ability to carry out self-monitoring of blood glucose, risk for hypoglycemia, contraindications to oral medications, health literacy, and financial and other resources. Traditional oral therapies that may be used after the patient leaves the hospital include sulfonylureas, α-glucosidase inhibitors, thiazolidinediones, and metformin. α-Glucosidase inhibitors are limited by gastrointestinal adverse events, and thiazolidinediones by fluid retention and increased risk for heart failure. Thiazolidinediones also require a long period of administration for onset glucose lowering and are not suitable for transitioning hospitalized patients who have been receiving insulin to outpatient care. Metformin is contraindicated in patients with renal, cardiac, or pulmonary insufficiency. Incretin-based therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have limited use in hospitals, but may be suitable for the transition to outpatient treatment. The most common adverse events with glucagon-like peptide-1 inhibitors involve the gastrointestinal system. More formal studies of treatment regimens for patients with hyperglycemia leaving the hospital are needed to guide care for this group.