Blog | Wednesday, August 7, 2013

QD: News Every Day--Tread lightly on adjusting inpatients’ drug regimens for chronic conditions

Hospital-based physicians would serve patients well by leaving ambulatory care drug regimens up to outpatient providers, a commentary reads.

Corresponding author Michael A. Steinman, MD, FACP, and a colleague outlined their ideas in an opinion piece in JAMA Internal Medicine after considering the case of an 82-year-old man with severe chronic obstructive pulmonary disease and remote coronary artery bypass grafting who was admitted for chest pain.

The man’s previously normal blood pressure rose after admission, likely because of his illness. Even though acute coronary syndrome was ruled out, the patient was prescribed losartan potassium, 25 mg daily, and low-dose metoprolol tartrate, twice daily and continued on the drugs after discharge. Outpatent follow-up three days later recorded the man’s blood pressure at 85/45 mm Hg.

Other examples of discordant care might include continuing blood glucose medications that result in hypoglycemia or adding statins and bisphosphonates that make medications regimens more complex, resulting in decreased adherence, the authors wrote.

It’s best just to improve coordination between inpatient and outpatient providers, the authors wrote.

“In most cases, the best approach to chronic disease in hospitalized patients is for physicians to be reluctant to intensify long-term therapies,” the authors wrote. “This approach requires a clear definition of the role of the inpatient physician in chronic disease management. Determining whether acute control of chronic disease benefits the patient’s near-term health is essential. If the answer is yes, it is usually appropriate to intensify therapy. If the answer is no, it is usually best to leave the outpatient regimen untouched.”

While this is particularly important for patients whose chronic conditions have been well-controlled on an outpatient basis, the lesson still applies to those with poor baseline control, the authors wrote.

“Many cases of suboptimal disease control in the outpatient setting reflect limited access to health care, prior adverse events when therapy was intensified, or medication nonadherence. In such situations, starting treatment with a drug and sending the patient home with the new medication will do little to improve long-term outcomes,” they wrote. “In contrast, hospitalization can provide an excellent opportunity to address underlying barriers to long-term disease control, for example, by referring a patient to primary care, involving social workers to address social and financial obstacles to care, or having pharmacists teach about proper medication use.”

In case you missed it

Uncertain about what medical specialty to choose (or why you chose yours, for you more-experienced doctors out there)? Cartoonist and physician Dr. Fizzy has posted a humorous online algorithm for what criteria define the medical specialties, and how internal medicine fits in for the undecided.