The use of sodium‐glucose co‐transporter 2 inhibitors in the inpatient setting: Is the risk worth taking?

Abstract

What is known and objective In the outpatient setting, sodium‐glucose co‐transporter 2 inhibitors (SGLT2i) are recognized as effective agents to optimize glycaemia and also developing robust evidence for cardiovascular (CV) and renal protection in people with type 2 diabetes, particularly those at higher risk. However, data on the safety and efficacy of these drugs in hospitalized patients remain limited. The purpose of this review is to discuss the balance between risks and benefits of SGLT2i use in the inpatient setting. Methods PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the mechanisms of action and the safety profile of SGLT2i in the context of their use in hospitalized individuals are summarized and discussed in this narrative review. Results and discussion The rationale behind the use of these agents in the inpatient setting is based on the low risk of hypoglycaemia, the practical dosing scheme and the potential to decrease subsequent heart failure admission rates. In addition, data from animal studies indicate the ability of SGLT2i to ameliorate oxidative stress, suppress sympathetic activity, enhance autophagy and promote cardiac remodelling, when administered in the acute phase of CV episodes. On the other hand, these drugs have been linked to specific adverse events related to their mechanism of action, including an increased risk of euglycaemic diabetic ketoacidosis and volume depletion, which raises concerns over their usefulness in inpatients, particularly individuals with multimorbidities. What is new and conclusion Potential benefits deriving from the use of SGLT2i in the inpatient setting cannot mitigate possible risks, at least until robust evidence on their efficacy in hospitalized individuals become available. The concept of administering these agents in the acute phase of CV episodes, in people with or without diabetes, requires further evaluation in appropriately designed clinical studies.

Sodium-Glucose Cotransporter-2 Inhibitors at Discharge from Cardiology Hospitalization Department: Decoding A New Clinical Scenario

“…Additionally, the prevalence of T2DM among hospitalized patients in cardiology is very high (30%) [ 20 ], and even a 16% of new diagnosis of T2DM could be detected if an adequate screening was requested (according to the guidelines’ recommendation [ 6 , 7 ]) during cardiology hospitalization [ 20 , 21 ]. Therefore, cardiology hospitalization should be considered as an opportunity for the detection of T2DM and for the initiation of antidiabetic drugs with cardiovascular benefits [ 13 ].…”

“…However, the trials of SGLT-2 inhibitors were performed in stable, outpatient T2DM cases [8][9][10]. Until now, no data is available on the safety and efficacy of SGLT-2 inhibitors at hospital discharge [13].…”

“…Nevertheless, the early initiation of SGLT-2 inhibitors could become a treatment option due to the size of their effect and the rapid onset of action, especially considering that the greatest risk of cardiovascular events and HF hospitalization is concentrated during the first year after hospital discharge [12]. Although there has been experience with initiation during the hospitalization [13], it seems complicated in terms of hemodynamic stability. Therefore, we suggest it could be tested immediately at clinical discharge, as a new scenario.…”

Oral antidiabetes agents for the management of inpatient hyperglycaemia: so far, yet so close

“…There are concerns, however, about the use of SGLT2 inhibitors in the hospital setting, mainly because an increased risk of euglycaemic diabetic ketoacidosis and volume depletion that has been reported to occur rarely in people treated with SGLT2 inhibitors []. Notably, precipitating factors for diabetic ketoacidosis, such as sepsis, emergency surgery, acute renal failure, and reduction in insulin dose are commonly seen in inpatients [46]. Moreover, the peri‐operative management of people on treatment with these agents deserves special consideration.…”

“…Data on the safety and efficacy SGLT2 inhibitors in the inpatient population are currently lacking. The practical dosing schemes, their potential to decrease subsequent heart failure rates and the low risk of hypoglycaemia related to these agents render them an interesting option for the management of inpatients with hyperglycaemia [46]. Moreover, data from animal studies suggest that SGLT2 inhibitors have the potential to ameliorate oxidative stress, downregulate sympathetic activity, and improve autophagy and cardiac remodelling, when administered in the acute phase of cardiovascular episodes [47,48].…”