SGLT-2s
Aiya Almogaber, PharmD
SGLT-2 inhibitors have become a cornerstone in managing T2D, heart failure, and chronic kidney disease, offering significant benefits for outpatient care. However, their role in hospitalized patients remains a subject of debate due to potential safety concerns, particularly the risk of ketoacidosis. A recent systematic review and meta-analysis, published in Diabetes Care examines the risks and benefits of in-hospital SGLT-2 inhibitor use, with findings that could shape future clinical guidelines.
Assessing the evidence
To better understand the impact of SGLT-2 inhibitors in hospitalized patients, researchers analyzed data from 23 randomized controlled trials and 20 observational studies, including nearly 20,000 patients. The review focused on safety outcomes, particularly the risk of diabetic ketoacidosis (DKA), and key clinical measures such as hospital readmission rates, mortality, and acute kidney injury (AKI). The diverse study populations included patients admitted with heart failure, myocardial infarction, and those undergoing surgery, providing a broad look at the potential risks and benefits in an inpatient setting.
Balancing risks and benefits
One of the main concerns regarding in-hospital SGLT-2 inhibitor use is the risk of DKA, a potentially serious complication. Unlike traditional DKA, which occurs with high blood glucose, SGLT-2 inhibitor-associated DKA can develop even with normal or mildly elevated glucose levels, making it harder to detect.
The meta-analysis found that while ketoacidosis rates were numerically higher in hospitalized patients receiving SGLT-2 inhibitors, the difference was not statistically significant. This suggested that while the risk remains, it should be weighed against the benefits in appropriate patient populations. Beyond ketoacidosis, the study found that SGLT-2 inhibitors were associated with a significantly lower incidence of AKI, a frequent complication among hospitalized patients. This finding aligns with prior research demonstrating the renal protective effects of these medications, suggesting they may provide kidney benefits even duringhospitalization.
Impact on readmissions and mortality
The study also suggested that SGLT-2 inhibitors could improve key clinical outcomes in certain hospitalized patients. Among those with heart failure, SGLT-2 inhibitor use was linked to fewer hospital readmissions and urgent care visits, likely due to their ability to reduce fluid overload and improve cardiac function.
Additionally, hospitalized patients with heart failure who received SGLT-2 inhibitors had a lower mortality rate compared with those in the control group. While the overall reduction in mortality across all hospitalized patients was not statistically significant, the heart failure subgroup findings indicated that these medications could play a valuable role in managing this high-risk population.
These results highlight the potential for a shift in how clinicians approach SGLT-2 inhibitor use in the hospital setting. Rather than discontinuing them upon admission, providers may need to consider individual risk factors and balance the potential benefits—such as improved heart and kidney function—against the known risks.
A shift in treatment strategies
The findings suggested that inpatient SGLT-2 inhibitor use should not be universally avoided but rather tailored to individual patient needs. While ketoacidosis concerns persist, particularly in patients with poor oral intake or those undergoing surgery, the benefits, such as reduced readmissions, improved heart failure outcomes, and lower AKI incidence, are significant considerations.
For patients with heart failure, continuing or even initiating SGLT-2 inhibitors during hospitalization may provide meaningful clinical advantages. However, careful patient selection and monitoring remain crucial to ensuring safety. As hospital protocols evolve, this study may guide a more nuanced approach to SGLT-2 inhibitor use in inpatient settings. Future research, particularly in broader patient populations, will be key to determining whether these medications should become a standard part of hospital care or remain primarily an outpatient treatment. ■