DPP-4 inhibitors may be effective for some cases of inpatient hyperglycemia

A narrative review considered the available evidence on use of metformin, thiazolidinediones, sulfonylureas, sodium-glucose cotransporter-2 inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors in the hospital.

Dipeptidyl peptidase-4 (DPP-4) inhibitors may be effective for managing hyperglycemia in certain hospitalized patients, according to a recent study.

Researchers performed a narrative review of research published through January 2020 to examine the available evidence on use of oral antidiabetes agents in the hospital, identifying studies that looked at efficacy and safety profiles. Most recommendations currently favor subcutaneous or IV insulin for glucose lowering in hospitalized patients with diabetes or stress hyperglycemia and advise against oral drugs due to safety concerns, the authors noted. Data on metformin, thiazolidinediones, sulfonylureas, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and DPP-4 inhibitors were considered. The results were published May 23 by Diabetic Medicine.

Little evidence was available on use of metformin in the hospital setting, probably due to concern about lactic acidosis and other adverse events, the review found. A small study found that inpatients with acute stroke and type 2 diabetes who received thiazolidinediones had improved functional outcomes but did not differ from a placebo group in length of rehab stay or final discharge destination. This drug class can also cause fluid retention, which can destabilize patients with heart failure or chronic kidney disease, the authors said.

Sulfonylureas are strongly linked to risk for severe, prolonged hypoglycemia, especially in patients with renal impairment, which is common in hospital settings, the review noted. In addition, a study found that hypoglycemic events during the night were more common in hospitalized patients who received a sulfonylurea versus insulin, indicating a “significant barrier” to use of these drugs in this setting, the authors wrote. They noted that data on the safety and efficacy of SGLT-2 inhibitors in hospitalized patients are currently lacking.

DPP-4 inhibitors, meanwhile, have a good safety and efficacy profile, and a few well-designed randomized controlled trials support their use in hospitalized patients with type 2 diabetes, alone or in combination with basal insulin, the review found. Some studies have indicated a higher risk for pancreatitis with these drugs, so their use in patients with gallbladder disease, for example, should involve careful consideration of risks and benefits, the review said.

The authors of the review noted that the available studies are limited but concluded that “there is no robust evidence to support the use of metformin, thiazolidinediones, sulfonylureas and [SGLT-2] inhibitors in the hospital setting, although particular aspects of their effects on acute outcomes deserve further evaluation in appropriately designed clinical trials.” Evidence supports the use of DPP-4 inhibitors, however, in certain hospitalized patients with type 2 diabetes, such as those with mild to moderate hyperglycemia and those who are in stable clinical condition, they said. “The challenge for future research in the field,” the authors wrote, “is to clearly define the clinical characteristics of inpatients that make them suitable for treatment with oral agents.”