Skip to main content

Inappropriate Management of Hypertension and Diabetes in the Hospital

A great Viewpoint in JAMA Internal Medicine describes an important and common cause of over treatment and medication errors in hospitalized patients:   Intensifying treatment for chronic problems that are best managed in the outpatient setting.  The two most common culprits are hypertension and diabetes.

As our UCSF colleagues, Michael Steinman and Andrew Auerbach aptly note in this viewpoint, many patients, especially older patients, are admitted for acute problems like pneumonia.  They also have hypertension, diabetes, or other conditions that are unrelated to the reason for admission.

A well intentioned hospital physician may see the hospitalization as an opportunity to "tune up" the patient by intensifying treatment for these conditions.  But, this usually does more harm than good.  Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving management to the outpatient doctor.

There are two big problems with intensifying treatment for chronic conditions such as hypertension and diabetes in the hospital.

First, acute illness often causes transiently worse control of hypertension and diabetes.  Control will likely return to normal after the acute illness resolves.  But when treatment is intensified in the hospital, the patient goes home dangerously over treated.  In their viewpoint, Steinman and Auerbach give an example of a patient in whom intensification of blood pressure treatment in the hospital led to potentially dangerous low blood pressure after the patient went home.

Second, it is simply impossible to determine the ideal regimen for blood pressure and glucose control in the hospital.  It makes no sense to try to carefully titrate meds for these conditions in the hospital where the patient's activity and dietary regimen is completely different from their home regimen.  We may feel good by making all the numbers look good in the hospital but the numbers will be very different when the patient goes home.  Close titration of blood pressure and blood sugar in the hospital is usually futile.

Hospital physicians should think twice before trying to change established outpatient regimens for hypertension and diabetes in the hospital.  Changes should only be made in consultation with the outpatient physician.

by: Ken Covinsky


Bruce Scott said…

In particular, hospitalists and inpatient resident ward teams seem to target particularly aggressive goals in elderly patients that would be more appropriate in younger patients but dangerous and inappropriate in our elders. I NEVER get called about them before these changes are made. Moderate Alzheimer's patients get put on insulin or new anti-hypertensives.

Either my eyes are getting worse or the Captchas are getting harder. Pretty soon they may as well say "Please prove you're under 40" instead of "Please prove you're not a robot".
ken covinsky said…
Bruce--thank you for your comments. I think you are on to something really important---the hospital as a contributor to overmedicalization and polypharmacy in the very frail and patients with dementia. It strikes me that frailty and dementia often have no impact on the care provided by inpatient teams.

Your comment makes me think of the important observation Joan Teno made about feeding tubes in patients with advanced dementia. 2/3 are inserted during acute care hospitalizations---not in the nursing home. This all illustrates the importance of leaving treatment decisions that do not need to be made acutely to the outpatient team that best knows the patient.
Moshe said…
Re: Feeding tubes in acute hospitalizations

As a resident in internal medicine, we deal with these issues all the time. Elderly patients are hospitalized with pneumonia, UTI, bacteremia, etc... Their level of consciousness is decreased and they are simply unable to eat on their own. Should we starve them for 3-5 days (presuming that they will recover) until they are discharged to the nursing home? Obviously, when they are stable they can eat normally (albeit with help), in acute illnesses they are unable to do so.

Please don't blame us for not starving our patients to death.
Eric Widera said…

Ken's referenced an article that looks at endoscopic or surgical insertion of a gastrostomy tube during a hospitalization. This is not nasogastric tube for a couple days while delirium is resolving. It's also not a question of starving someone vs feeding by the PEG, as careful hand feeding and comfort feeding should be the standard of care for these patients.

The sad state of affairs with these PEG or PEJ tubes is that it matters greatly on what hospital you get admitted to. In a study of NH residents admitted to the hospital the rate of feeding tube insertion varied 0 to 38.9 per 100 hospitalizations. Higher rates in for-profit hospitals that were large and had more ICU use in the last 6 months of life (JAMA. 2010;303(6):544-550).
Janice Reynolds said…
Returning to the subject of over treating of HTN and DM when the elderly are hospitalized. The point that acute illness causes changes in both of these is an important one to remember which is why unless they were a reason or contributing reason they shouldn't be addressed during the acute hospitalization. If someone's HCA1B comes back at 8 then get things started but don't get drastic. One case I remember a woman with fairly advanced Dementia had broken her hip and the family had elected to go with palliative care instead of surgery. She was only taking a little Ensure-not eating at all (and this was not new for her) and her blood sugars were being done QID. This upset her family and as a palliative care nurse I was able to get them dropped to BID (couldn't get them stopped entirely). The orthopedic surgeon was very upset as he had heard one of the intensivist lecture on keeping tight glycemic control in order to enhance healing. He didn't seem to "get" that our goal was to make this person as comfortable as possible and "healing" would not be likely at this point in this lady's life. So when tweaking un-acute problems maybe asking what our "goal" for this hospitalization is may be helpful.
kathy kastner said…
I learn so much from GeriPal and comments.. This is yet anther important piece for us non- healthcare professionals to know and accept, so we can make decisions borne of understanding of a larger picture rather than guilt or pressure (or knee jerk reaction). Many thanks for putting this into humane perspective. Although meant for healthcare professionals, I'll be linking to it on my made-for-real-people-blog Kathy Kastner

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …