5.3.0.0 Noninsulin Therapies
The safety and efficacy of noninsulin antihyperglycemic therapies in the hospital setting is an area of active research. A few recent randomized pilot trials in general medicine and surgery patients reported that a dipeptidyl peptidase 4 inhibitor alone or in combination with basal insulin was well tolerated and resulted in similar glucose control and frequency of hypoglycemia compared with a basal-bolus regimen (46-48). However, an FDA bulletin states that providers should consider discontinuing saxagliptin and alogliptin in people who develop heart failure (49). A review of antihyperglycemic medications concluded that glucagon-like peptide 1 receptor agonists show promise in the inpatient setting (50); however, proof of safety and efficacy awaits the results of randomized controlled trials (51).
Moreover, the gastrointestinal symptoms associated with the glucagon-like peptide 1 receptor agonists may be problematic in the inpatient setting.
Regarding the sodium–glucose transporter 2 (SGLT2) inhibitors, the FDA includes warnings about diabetic keto-acidosis (DKA) and urosepsis (52), urinary tract infections, and kidney injury (53) on the drug labels. A recent review suggested SGLT2 inhibitors be avoided in severe illness, when ketone bodies are present, and during prolonged fasting and surgical procedures (3). Until safety and effectiveness are established, SGLT2 inhibitors cannot be recommended for routine in-hospital use.