Background: Diabetes is an exceedingly common disease encountered by medical trainees, with over 8 million hospitalizations in 2018 listing type 1 or type 2 diabetes as a diagnosis (1). Evidence supports continuing certain oral diabetes medications during admission when safe, reflected in recent consensus statements from professional societies (2,3). Nevertheless, oral medications are often held in favor of insulin (4). While previous studies have examined trainees’ knowledge of insulin regimens and oral diabetes medications, they have not assessed trainees’ actual practices of continuing patients on oral medications during inpatient stays (5–8). We developed a survey for medical trainees examining their knowledge of oral diabetes medications and self-reported practice patterns, as well as their knowledge of insulin-based therapies.
Methods: An online survey was administered prior to an educational lecture on inpatient diabetes management. Trainees in internal medicine ranging from third-year medical students to senior residents at a large, urban academic medical institution were anonymized and assessed on their knowledge, attitudes, and self-efficacy regarding diabetes management in the inpatient setting.
Results: Forty-three trainees completed the survey. Most respondents (63%) felt “neutral” or “comfortable” in managing diabetes on inpatient rotations. Regarding oral diabetes medications, most trainees considered metformin (79%), DPP-4 inhibitors (79%), GLP-1 receptor agonists (67%), and SGLT-2 inhibitors (88%) safe options for inpatient continuation. When asked specifically about metformin, 26% of trainees reported they “never” continue the drug during admission, 28% of trainees “rarely” continued it, and 47% of trainees reported continuing metformin in at least half of their admissions. Interns and medical students were more likely to state that they “never” or “rarely” continue metformin compared to senior residents (61% vs. 33%). Seventy-seven percent of respondents cited “concern for lactic acidosis and worsening renal function” as a reason for discontinuing metformin, with 33% of respondents indicating it as the sole reason for discontinuation. Sixty percent of respondents also cited a hospital culture of discontinuing oral medications in favor of insulin therapy as a reason for discontinuation. In case-based scenarios where continuing oral medications was reasonable, 47% of respondents appropriately identified metformin for continuation.
Conclusions: While most of our trainees considered metformin and other oral medications safe for inpatient use, the self-reported frequencies of actual use revealed a hesitancy to continue the drug during hospitalization. Trainees in large part cited concern for lactic acidosis and worsening renal function as well as hospital culture as the reasons for discontinuation. Moreover, less than half of the respondents were able to identify scenarios in which continuing oral diabetes medications would have been appropriate. Our results suggest that educational interventions are needed to rectify the misconception surrounding the risks of oral agents for inpatient diabetes management.