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Managing Selected Chronic Conditions in Hospitalized Patients

This is a corrected version of the article that appeared in print.

Robert L. Gauer, MD
Alain Abellada, MD
Matthew Stewart, MD
Ryan Kozloski, MD

American Family Physician. 2024;109(2):134-142.

Author disclosure: No relevant financial relationships.

The management of chronic illnesses should continue during hospitalization. Some chronic conditions require immediate intervention, whereas intensification of therapy for other conditions may be delayed until after discharge. Factors such as pain, anxiety, poor sleep hygiene, and concurrent illness can result in a transient elevation of blood pressure. Acute lowering of blood pressure in hospitalized patients who do not have target-organ damage is not recommended and may lead to harm. If treatment is needed, intravenous antihypertensive agents should be avoided. Patients with diabetes mellitus require continued management of their blood glucose while hospitalized. Noninsulin agents are typically discontinued. Blood glucose levels should be managed using basal, prandial, and/or correction insulin. During hospitalization, conservative blood glucose targets (140 to 180 mg per dL) are preferred vs. lower targets to reduce length of stay, mortality, and the risk of hypoglycemic events in critically ill patients. Alcohol use disorder is common and hospitalization for other conditions necessitates identification and management of alcohol withdrawal syndrome. The mainstay of therapy for alcohol withdrawal syndrome is benzodiazepines; however, phenobarbital is an alternative treatment option. The risk of venous thromboembolic disease is significantly increased for hospitalized patients. Venous thromboprophylaxis is recommended for all but low-risk patients. Pharmacologic prophylaxis with subcutaneous low-molecular-weight heparin is preferred; mechanical prophylaxis is an alternative for patients who are at high risk of bleeding or have contraindications to anticoagulation.

Patients who are hospitalized require continued management of their preexisting chronic medical conditions. This article reviews current evidence and recommendations for management of hypertension, diabetes mellitus, alcohol withdrawal syndrome (AWS), and venous thromboembolism (VTE) risk in hospitalized patients.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Acute management of severe asymptomatic hypertension in hospitalized patients should be avoided because it increases the risk of adverse composite outcomes, acute kidney injury, and myocardial infarction.2,4–8 B High-quality retrospective cohort studies
Hospitalized patients with diabetes should discontinue noninsulin therapies, and blood glucose levels should be managed with basal, prandial, and/or correction insulin.14,16,17,19 C Expert opinion and clinical practice guidelines
Alcohol withdrawal symptoms should be assessed in all patients with alcohol use disorder at hospital admission and managed with benzodiazepines or phenobarbital.27–29,32 C Expert opinion and clinical practice guidelines
Except for those classified as low risk by a clinical prediction score, prophylaxis for venous thromboembolism is recommended for hospitalized patients to reduce the risk of venous thromboembolic disease.48–50 A Meta-analysis and clinical practice guidelines

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

BEST PRACTICES IN HOSPITAL MEDICINE

Recommendations From Choosing Wisely
RecommendationSponsoring organization
Do not routinely prescribe VTE prophylaxis to all hospitalized patients; use an evidence-based risk stratification system to determine whether a patient needs VTE prophylaxis. If the patient does warrant prophylaxis, use a bleeding risk assessment to determine whether mechanical prophylaxis is more appropriate than pharmacologic prophylaxis.Society of Hospital Medicine – Adult Hospital Medicine

Note: For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/pubs/afp/collections/choosing-wisely.html.

VTE = venous thromboembolism.

ROBERT L. GAUER, MD, is a hospitalist in the Department of Internal Medicine at Womack Army Medical Center, Fort Liberty, N.C., and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

ALAIN ABELLADA, MD, is a family medicine hospitalist and faculty at Womack Army Medical Center Family Medicine Residency Program and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences.

MATTHEW STEWART, MD, is a hospitalist at Womack Army Medical Center.

RYAN KOZLOSKI, MD, is a resident in the Department of Internal Medicine at Womack Army Medical Center.

Address correspondence to Robert L. Gauer, MD, Womack Army Medical Center, Family Medicine Residency Clinic, 2817 Rock Merritt Ave., Bldg. 4, Fort Liberty, NC 28310 (robertgauer@yahoo.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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