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.

Management of Hypertension

EPIDEMIOLOGY

The prevalence of hypertension in the inpatient setting is between 51% and 72%, based on 24-hour blood pressure monitoring.^1,2 The average length of hospitalization is six days.³ Clinicians can be inconsistent with intensification of antihypertensive therapy, and 37% to 77% of patients remain hypertensive at discharge.¹ Patients with hypertension are often treated with intravenous or oral medications (8%) during hospitalization or discharged with a new anti-hypertensive medication (9%). Both approaches increase the risk of harm, including acute kidney injury (10.3% vs. 7.9%; P < .001) and myocardial infarction (1.2% vs. 0.6%; P = .003).⁴ Blood pressure lability during hospitalization and the lack of short-term harm from higher blood pressure supports a conservative approach to hypertension during hospitalization.

Multiple trials in outpatient, inpatient, and emergency department settings have shown that treatment of severe asymptomatic hypertension (blood pressure greater than 180/110 mm Hg) has no benefit, and in some cases leads to harm.^2,4–9 Despite the evidence, inpatient clinicians commonly treat patients with severe asymptomatic hypertension with oral and intravenous antihypertensive therapy. Hospital order sets routinely have preset treatment protocols when blood pressure measurements exceed 180/100 mm Hg, and in some cases, when systolic blood pressure is greater than 160 mm Hg. No studies demonstrate that patients with severe asymptomatic hypertension will progress to a hypertensive emergency.¹

Hospitalized patients with elevated blood pressure often see a decrease of 20 mm Hg with subsequent measurements.⁴ Thirty minutes of rest is as effective as antihypertensive medications and should be first-line therapy.¹⁰ Conditions associated with transient blood pressure elevations (e.g., pain, transient kidney dysfunction, anxiety, fluid overload, agitation, nausea, poor sleep hygiene, urinary retention, nicotine or alcohol withdrawal) should be addressed.¹¹

PHARMACOLOGIC TREATMENT

Treatment should be considered in patients who have symptoms of acute elevated blood pressure, such as headache, lightheadedness, nausea, atypical chest pain, or epistaxis. Patients with coronary artery, cerebrovascular, or chronic kidney disease, or nonoperative aortic aneurysm are considered high risk for adverse events. In these patients, pharmacologic management of sustained severe hypertension should be initiated after other causes of blood pressure elevation have been excluded. Figure 1 provides an algorithm for inpatient management of severe hypertension.^11,12

Clinicians should avoid using intravenous therapy. Short-acting antihypertensive therapies (i.e., clonidine, captopril, hydralazine, labetalol, nifedipine, prazosin, and 2% topical nitroglycerin) should be used with extreme caution because they can lower blood pressure too quickly.¹³ Lowering blood pressure by more than 20% to 25% can result in cerebrovascular or myocardial ischemia.¹¹ Low-risk patients with no history of hypertension and sustained severe asymptomatic hypertension do not require inpatient treatment but should have outpatient follow-up with their primary care physician.

Diabetes Management

Patients with diabetes have a threefold higher risk of hospitalization; increased length of stay; and higher rates of infection, morbidity, and mortality.^14,15 Up to 25% of patients with no known diabetes will develop hyperglycemia (e.g., stress hyperglycemia, undiagnosed diabetes) during hospitalization. ¹⁶ Obtaining a blood glucose level for all patients at admission is recommended. An A1C level should be obtained for patients with diabetes who have not had one in the past three months and those with a blood glucose level greater than 140 mg per dL (7.77 mmol per L) at admission. The 2022 Endocrine Society clinical practice guidelines recommend using continuous blood glucose monitoring in patients with diabetes who require insulin and are hospitalized for noncritical illnesses, but some hospitals may not have this capability.¹⁷

The NICE-SUGAR trial found that mortality rates were increased in critically ill patients who had intensive blood glucose control (81 to 108 mg per dL [4.5 to 5.99 mmol per L]) compared with conventional blood glucose control (140 to 180 mg per dL [7.77 to 9.99 mmol per L]).¹⁸ The benefits and harms of intensive glycemic control in patients hospitalized for noncritical illnesses are unknown. Surgical patients have significantly less complications with basal-bolus insulin compared with correction insulin alone.¹⁴ The American Diabetes Association recommends insulin if blood glucose is 180 mg per dL or greater. They acknowledge that lower goals (110 to 140 mg per dL [6.11 to 7.77 mmol per L]) can be used if there is no increased risk of hypoglycemia, such as in patients after heart surgery or those who are critically ill after surgery.¹⁹ The Endocrine Society recommends a broader goal of 100 to 180 mg per dL (5.55 to 9.99 mmol per L).¹⁷

MEDICATION TREATMENT

A basal-bolus insulin regimen is recommended for treatment of hyperglycemia in hospitalized patients.²⁰ Basal-bolus insulin is a combination of: (1) basal insulin, (2) prandial insulin (i.e., bolus premeal insulin), and (3) correction insulin.^14,16,17,19 The use of basal-bolus insulin can require four or five separate injections using two different insulin formulations and is dependent on nutritional intake. Sliding scale insulin alone is not recommended except in patients with well-controlled, mild type 2 diabetes who are not on insulin.^21,22 Sliding scale insulin is a reactive approach to hyperglycemia and not anticipatory glycemic management. Sliding scale insulin used with basal and prandial insulin therapies is often referred to as correction insulin. Table 1 provides definitions for these insulin terms. The amount of correction insulin required will guide titration of basal and prandial regimens.

Patients with well-controlled diabetes who do not require insulin and are able to eat, have a short anticipated hospitalization, and are not critically ill may continue oral hypoglycemic agents; noninsulin agents should be discontinued in other patients.^14,16,17,19 Oral hypoglycemic agents are more likely to be stopped during longer admissions. These include metformin (should be temporarily withheld for iodinated contrast agents; risk of lactic acidosis), sulfonylureas (unpredictable hypoglycemia), meglitinides (increased risk of cardiovascular events), and thiazolidinediones (risk of peripheral edema; should be avoided in heart failure). Recent studies have shown that glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl-peptidase-4 (DPP-4) inhibitors for mild hyperglycemia have outcomes similar to basal-bolus insulin.^16,23 Use of GLP-1 agonists or DPP-4 inhibitors with basal insulin has similar glycemic control and less hypoglycemia compared with basal-bolus insulin alone.²² Sodium-glucose cotransporter-2 inhibitors are used for glycemic control, particularly in patients with heart failure. An approach to glycemic management in inpatients with diabetes is outlined in Table 2.^14,15,23

Patients with an insulin pump can continue using it during hospitalization if they are not critically ill and do not have an impaired level of consciousness or poor blood glucose control. It is recommended that hospitals have personnel with expertise in insulin pumps. Patients whose insulin pumps are discontinued (i.e., due to critical illness, equipment failure, lack of supplies, altered mental status, or the need for magnetic resonance imaging) should be started on subcutaneous or intravenous insulin within 30 minutes. Patients with inadequately controlled diabetes or an elevated A1C level should have intensification of therapy and education by a certified diabetic educator before discharge. These interventions reduce hypo- and hyperglycemic events, surgical infection rates, and length of stay.²⁴

Management of Alcohol Use Disorder and Withdrawal Syndrome

RISK ASSESSMENT

AWS is a life-threatening condition with a 3% mortality rate. The condition develops in 2% to 7% of patients with heavy alcohol use who are admitted to general medical units.²⁵ Mortality is as high as 23% in patients hospitalized for AWS.²⁶ Of hospitalized patients, 33% meet the criteria for alcohol dependence.²⁷ Symptoms of AWS begin six hours after the patient's last drink and range from mild to severe (Table 3).^28–30 An alcohol use history should be obtained for all hospitalized patients and include complications associated with past alcohol withdrawal, such as seizures or delirium tremens.^27–29 Most patients will develop only mild withdrawal symptoms; however, 25% will develop more severe AWS.²⁶

Patients with alcohol use disorder who are at risk of AWS require regular assessment using the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar; https://www.mdcalc.com/calc/1736/ciwa-ar-alcohol-withdrawal) or the Prediction of Alcohol Withdrawal Severity Scale (PAWSS; https://www.mdcalc.com/calc/10102/prediction-alcohol-withdrawal-severity-scale). A CIWA-Ar score of less than 8 or a PAWSS score of less than 4 indicates mild AWS, a CIWA-Ar score between 8 and 15 indicates moderate AWS, and a CIWA-Ar score of 15 or more or a PAWSS score of 4 or more is associated with severe AWS.^26,31 An assessment should be performed at least every four to eight hours but may be needed hourly to assess response to medication.

Electrolytes (e.g., potassium, magnesium, phosphate), fluids, and nutritional deficiencies should be corrected as needed. Administration of thiamine and glucose are recommended to prevent Wernicke encephalopathy.³² Critical care may be needed for patients with past complications, such as delirium tremens or withdrawal seizures, frequent sedative dosing, and severe medical complications associated with alcohol use disorder (e.g., gastrointestinal bleeding, severe pancreatitis, marked electrolyte abnormalities, severe hepatic dysfunction, sepsis).

PHARMACOLOGIC TREATMENT

The American Society of Addiction Medicine recommends the use of short-acting (e.g., lorazepam, oxazepam) or long-acting (e.g., diazepam, chlordiazepoxide) benzodiazepines as first-line treatment for AWS.³² Symptom-triggered dosing is preferred because it reduces length of stay and total benzodiazepine use. Patients at higher risk of AWS may benefit from front loading or a fixed-dose taper.³³ Mild AWS can be treated with a four-day, fixed taper (i.e., diazepam, 10 mg every six hours on day 1, every eight hours on day 2, every 12 hours on day 3, and at night on day 4) or symptom-triggered dosing based on CIWA-Ar score. Moderate to severe AWS often requires intravenous loading doses (i.e., diazepam, 5 to 10 mg every 10 to 15 minutes, or lorazepam, 2 to 4 mg every 10 to 15 minutes) to achieve adequate sedation.³⁴ Conversion to oral dosing is recommended after loading with fixed or symptom-triggered dosing. Benzodiazepines are associated with hepatic encephalopathy, excessive sedation, and respiratory depression, particularly in patients with liver impairment. Lorazepam and oxazepam have a shorter half-life and are preferred in patients with advanced liver disease or acute alcoholic hepatitis.

Phenobarbital is another treatment option that can be used as an adjunct to benzodiazepines or as monotherapy ^35–40 (eFigure A). Phenobarbital has a rapid onset, a long half-life, wide therapeutic range, and no sedative effects at moderate doses. When using phenobarbital, the Richmond Agitation-Sedation Scale (https://www.mdcalc.com/calc/1872/richmond-agitation-sedation-scale-rass) offers a simple scoring system that requires only observation of the patient.

A 2023 systematic review (n = 11 trials) compared pheno-barbital with benzodiazepines. The evidence demonstrates safety, effectiveness, and noninferiority of phenobarbital alone or with benzodiazepines for AWS.⁴¹ There was no significant difference in length of stay, incidence of intubation, and the need for hospitalization (when phenobarbital was used in the emergency department).^42–44 Anticonvulsants such as carbamazepine, gabapentin, and valproic acid have also been used to treat mild AWS; however, there is no evidence of their effectiveness to treat severe AWS or delirium tremens.⁴⁵ Dexmedetomidine is used in the intensive care unit as an adjunct treatment for resistant alcohol withdrawal but does not prevent seizures or delirium tremens.³²

Patients with alcohol use disorder should be referred to an alcohol treatment program before discharge. Naltrexone (Revia) and acamprosate increase the likelihood of abstinence.⁴⁶ Naltrexone can be administered orally, once daily, or intramuscularly, every four weeks. Significantly elevated liver function enzymes (three to five times or more above normal range) and active opioid use limit the use of naltrexone. Acamprosate (three times daily) is well tolerated and ideal for patients with preexisting liver disease or those taking opioids.

Venous Thromboembolism Prevention

VTE disease is a common cause of hospital-acquired morbidity and mortality. The overall incidence of VTE in noncritically ill hospitalized patients is approximately 1.2%.⁴⁷ Appropriate VTE prophylaxis reduces morbidity and the overall risk of developing deep venous thrombosis or pulmonary embolism.⁴⁸ [corrected] Several prediction scores are available (e.g., Padua Prediction Score, the IMPROVE risk score, GENEVA risk score; https://www.mdcalc.com) to assess risk of VTE. Except for those at low-risk, all patients should receive prophylaxis, preferably with low-molecular-weight heparin, to reduce the risk of VTE disease.^48–50 Patients with respiratory failure, acute infection, active cancer, acute limb paralysis or immobility, acquired or inherited thrombophilia, autoimmune or inflammatory conditions, a history of heart failure or VTE, or kidney failure; who are 60 years and older; or who have been admitted to the intensive care unit require VTE prophylaxis.⁴⁹

Mechanical VTE prophylaxis (i.e., intermittent pneumatic compression devices) is recommended in patients at high risk of bleeding (e.g., IMPROVE Bleeding Risk Assessment Model) or who have contraindications to anticoagulation (e.g., active duodenal ulcer, bleeding within three months of admission, intracranial hemorrhage, scheduled invasive procedure, platelet count less than 50 × 10³ cells per μL [50 × 109 cells per L]).⁴⁹ Patients should be reevaluated daily to determine if pharmacologic VTE prophylaxis can be initiated. Combination pharmacologic and mechanical VTE prophylaxis has not been studied in hospitalized patients and is not recommended. There is an increased risk of major bleeding in patients with trauma and stroke with combined VTE prophylaxis compared with pharmacologic VTE prophylaxis alone.⁴⁹ Aspirin and warfarin should not be used for VTE prophylaxis in hospitalized patients. A 2023 study demonstrated that 81 mg of aspirin, twice daily, was noninferior to low-molecular-weight heparin, 30 mg subcutaneously, twice daily, in patients with surgically repaired extremity or pelvic fractures in the prevention of VTE.⁵¹ Patients currently taking oral anticoagulation for other indications (e.g., active VTE treatment, atrial fibrillation, prosthetic heart valve, left ventricular thrombus) do not require additional prophylaxis while hospitalized.⁵² Patients with total joint arthroplasty (e.g., knee, hip), significant paralysis from stroke, or mechanical ventilation should receive extended prophylaxis. Table 4 lists options for pharmacologic prophylaxis for VTE.^50,53–56

Data Sources: A search was performed in PubMed, UpToDate, Society of Hospital Medicine, American Diabetes Association, Endocrine Society clinical practice guideline, American Society of Addiction Medicine, American Psychiatric Association practice guideline, and American Society of Hematology. Key words included severe asymptomatic hypertension, hypertensive urgency, hypertensive emergency, emergency department, practice guidelines, inpatient, hospitalization, thromboembolism, prophylaxis, critically ill patients, medical adults, pharmacologic thromboprophylaxis, graduated compressing devices, direct oral anticoagulant, heparin, low-molecular-weight heparins, diabetes, glucose, diabetes type 1, diabetes type 2, sliding scale insulin, hyperglycemia, hospital standards, alcohol withdrawal syndrome, benzodiazepines, phenobarbital, and refractory alcohol withdrawal. Search dates: December 2022, and January, April, and November 2023.

The views expressed herein are those of the authors and do not necessarily reflect the official policy of the U.S. Department of the Army, U.S. Department of Defense, or U.S. government.