Dapagliflozin for inpatient hyperglycemia in cardiac surgery patients with type 2 diabetes: randomised controlled trial (Dapa-Hospital trial)

Pros and Cons of Inpatient SGLT2i Use for Hyperglycemia and Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2is), originally approved by the US Food and Drug Administration for glycemic control in type 2 diabetes mellitus (DM2), have shown substantial cardiovascular and renal benefits, leading to their expanded use in managing heart failure (HF) and chronic kidney disease in the outpatient setting. Despite these benefits, their use for inpatient hyperglycemia management is not universally endorsed due to safety concerns and inadequate data. However, emerging evidence suggests potential advantages of initiating SGLT2i treatment for patients during hospitalization in the setting of HF. While SGLT2is are not recommended for managing inpatient hyperglycemia, initiation during hospitalization for HF provides significant benefits. We review the current literature on the pros and cons of using SGLT2is in hospitalized DM2 and HF patients and provide guidance on careful patient selection and risk mitigation for inpatient use.

How Would You Treat This Inpatient With Type 2 Diabetes Mellitus? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Management of hospitalized patients with type 2 diabetes mellitus (T2DM) presents unique challenges. Two recently released guidelines, one from the American Diabetes Association and the other from the Endocrine Society, provide useful recommendations and evidence review to inform the care of medical inpatients with T2DM. These guidelines mostly agree, although there are slight differences in their recommendations. In these rounds, 2 expert diabetologists discuss their approach to inpatient management of T2DM, specifically regarding inpatient glycemic goals on the medical ward, the use of noninsulin antihyperglycemic medications, and patient safety strategies for patients receiving long-acting insulin. They conclude with recommendations for Mr. D, a real patient with T2DM admitted with a recurrent foot infection.

Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia

OBJECTIVE

Hyperglycemia in patients with type 2 diabetes mellitus is frequently encountered in the hospital setting. The recent guidelines for the management of inpatient hyperglycemia have included the use of dipeptidyl peptidase 4 inhibitors as an alternative to standard insulin therapy in select patients. This raises the question of the inpatient use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), which have gained increasing popularity in the outpatient setting because of beneficial cardiovascular and renal outcomes. This article describes the risks associated with the use of SGLT2i for the management of inpatient hyperglycemia.

METHODS

A literature review was performed using PubMed and Google Scholar for studies assessing the inpatient use of SGLT2i. Search terms included "SGLT2 inhibitors," "euglycemic DKA," "inpatient hyperglycemia," "DPP4 inhibitors," "hypovolemia," and "urinary tract infections." Studies not written in English were excluded. Forty-eight articles were included.

RESULTS

Review of the literature showed significant safety concerns with the use of SGLT2i for the inpatient management of hyperglycemia. Hospitalized patients treated with SGLT2i were at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections. When compared head-to-head, SGLT2i were not more effective for inpatient glycemic control than dipeptidyl peptidase 4 inhibitors and did not reduce insulin requirements when used in combination with insulin. Although SGLT2i can be considered for the treatment of congestive heart failure, they should be started close to or at the time of discharge.

CONCLUSION

Although SGLT2i are a preferred pharmacotherapy class for the outpatient management of type 2 diabetes mellitus, there are considerable safety concerns when using them in a hospital setting, and avoidance is recommended.