Intensive care unit (ICU) admissions may lead to unintentional discontinuation of long-standing, evidence-based drug therapies. In the August issue of the Journal of the American Medical Association, Bell et al conducted a population-based cohort study in Ontario, Canada, to investigate whether ICU or hospital admissions were associated with a greater risk for inadvertent discontinuation of long-term medications.

A total of 396,380 patients were included, with 47% hospitalized and 16,474 (4%) with an ICU stay.  Over 97% of all patients in the three groups had a primary care physician visit within one year of discharge.   Among all patients with an ICU stay, the incidence of medication discontinuation ranged from 22.8% for antiplatelet/anticoagulant medications to 5.4% for respiratory inhalers. Patients with an ICU stay were 1.48 times more likely to have discontinuation of a statin (95% confidence interval [CI], 1.39-1.57) and 2.31 times more likely to have discontinuation of antiplatelet/anticoagulant medications (95% CI, 2.07-2.57). Compared to controls, the adjusted odds ratio for medication discontinuation after an ICU stay varied from 1.11 for statins (95% CI, 1.05-1.18) to 1.29 for levothyroxine (95% CI, 1.17-1.41). In a preplanned secondary outcome analysis, the risk of death, emergent hospitalization or emergency department visit was significantly increased when statins or antiplatelet/anticoagulant medications were discontinued following hospitalization. The authors concluded that treatment in an ICU places patients at greater risk for unintentional discontinuation of long-term medications.

The high incidence of medication discontinuation in this study may not be caused solely by acts of omission.  ICU or hospital admission may lead to deliberate discontinuation of chronic medications for a wide variety of reasons.  Nonetheless, the authors selected 5 drug classes that have been associated with adverse consequences when discontinued.  Different levels of care provided during the admission, varying ICU and hospital lengths of stay, and lack of other clinical details may also explain the findings in this study.

An accompanying editorial by Jeremy M. Kahn, MD, MS, and Derek C. Angus, MD, MPH, FCCM, notes that solutions to better administer the complexities of medication management are much needed, and this study highlights the potential threats to patient welfare during transition through different levels of care within the health system.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.