AACE Podcast Episode 55 Summary

Title: Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia
Date: December 18, 2024
Host: Dr. Vin Tangpricha (AACE, Editor-in-Chief of Endocrine Practice)
Guest: Dr. Rifka Schulman Rosenbaum (Director of Inpatient Diabetes, Long Island Jewish Medical Center)

Overview

In this episode, Dr. Vin Tangpricha and Dr. Rifka Schulman Rosenbaum discuss the inpatient use of sodium-glucose cotransporter 2 (SGLT2) inhibitors for management of hyperglycemia. Dr. Schulman Rosenbaum provides expert insights drawn from her recent con-article (published in Endocrine Practice) arguing against the use of SGLT2 inhibitors for glycemic control in hospitalized patients. The episode also touches on the risks, current practices, and the distinction between indications for glycemic control and heart failure.

Guest Introduction and Credentials

• Dr. Schulman Rosenbaum is the Director of Inpatient Diabetes at Long Island Jewish Medical Center and a professor at the Zucker School of Medicine.
• She leads a multidisciplinary inpatient diabetes team at a high-volume center and has authored a comprehensive clinical guide on inpatient diabetes management.
• She is Chair-Elect for the 2025 AACE annual meeting.

"I'm the director of Inpatient Diabetes at Long Island Jewish Medical center ... and I run our [inpatient diabetes] service in our hospital." (02:12)

Key Discussion Points and Insights

The Evolving Landscape of Inpatient Diabetes Management

• Historically, inpatient diabetes care focused almost exclusively on insulin, often with sliding scales.
• Recent years have seen more nuanced approaches, including selective use of oral agents like DPP4 inhibitors for mild hyperglycemia.

"It’s really grown so much … The field has really grown so much." (03:50)

Should We Continue Home Diabetes Medications in the Hospital?

• Not always. In situations where the patient’s at-home regimen is appropriate and A1C is controlled, it may be reasonable.
• However, hospitalization is often an opportunity to reassess and adjust regimens to improve long-term outcomes, especially given outpatient endocrinology access hardships.

“This is a touch point where the inpatient endocrine team actually has the opportunity to really help people … why do they need to wait another six or twelve months … if I can help them right now?” (04:32)

SGLT2 Inhibitors: Risks in the Inpatient Setting

Euglycemic DKA (EDKA)

• SGLT2 inhibitors are associated with an increased risk of DKA, particularly euglycemic DKA. Dr. Schulman Rosenbaum reports frequent inpatient consults for this condition.

“I get consults for SGLT2 induced DKA or EDKA every single week, at least one, if not more.” (07:39)

Why is Hospitalization Riskier?

• Triggers include NPO status, surgical stress, poor oral intake, holding insulin, and acute illness.
• These conditions are common in hospitalized patients, compounding EDKA risk.

“... fasting, right? ... high stress situations ... all the things that happen in the hospital I've just listed.” (08:35)

Other Concerns

• Orthostatic Hypotension & Hypovolemia: SGLT2s can worsen these, dangerous for already fragile patients.
• Genitourinary Infections: Up to a quarter of inpatients may have Foley catheters, increasing UTI risks when on SGLT2s.
• Lack of Data: There is insufficient evidence for their use in inpatient glycemic management, with studies focusing more on CHF indications.

“If there’s another option … that doesn’t have those risks, that is definitely something to think about.” (11:21)

Preferred Alternatives in the Hospital

• For hyperglycemia, insulin remains the standard, with DPP4 inhibitors appropriate for mild cases.
• SGLT2 inhibitors should be held during inpatient stays for glycemic control.

“Basal bolus insulin for the pretty hyperglycemic patients and then consideration for DPP4 for the mild hyperglycemia patients seems a safer way to go.” (23:19)

SGLT2 Inhibitors for Heart Failure: An Exception

• Recent studies support SGLT2 inhibitors for heart failure (CHF) outcomes—often initiated near discharge, when the patient is stable.
• Risks persist, so initiation should be carefully timed and protocol-driven.

“There is some strong data towards using SGLT2s inpatient for CHF indication, but once a patient stabilized and once they're past that higher risk state, closer to discharge.” (23:48)

Gaps in the Evidence

• The field would benefit from high-quality RCTs specifically evaluating SGLT2s for inpatient glycemic control, focusing on safety (DKA, infections) and effectiveness.

“That’s the thing we would benefit from would be a study on inpatient use of SGLT2 specifically for glycemic control.” (20:19)

Notable Quotes and Memorable Moments

• On the lens of risk assessment:
  “It's important to pay attention to the lens through which you are trying to assess the frequency of the problem because ... it's very different from the inpatient side.” (07:55)
• On clinical experience with EDKA:
  “This is something we're seeing every day. So until we have better data that might support it, and maybe we never will, ... until then, [insulin and DPP4s] seems safer.” (23:19)
• On infection risk:
  “Up to a quarter of hospitalized patients have Foleys in place. Right. And so having a drug that potentially increases the risk of UTI ... the risk is even higher.” (11:58)
• Concluding summary:
  “The main kind of focus ... would be the concern regarding DKA and euglycemic DKA, which is a higher risk in the inpatient setting compared to the outpatient ... combined with potential risks of urinary tract infections ... as well as orthostatic hypotension ... All these inpatient factors that make me concerned.” (22:28)

Key Timestamps

• Guest Introduction & Roles: 01:08–02:52
• Growth of Inpatient Diabetes Management Field: 03:37–04:09
• Medication Management Philosophy: 04:09–05:47
• Clinical Practice: Home Medications in Hospital: 04:32–05:47
• Why SGLT2s Are a Special Concern Inpatient: 06:05–11:58
• Managing Common Admission Scenarios: 12:54–13:09
• SGLT2s for CHF Exception: 13:41–16:46
• Evidence Gaps & Research Needs: 19:24–22:14
• Take Home Messages/Risks & Recommendations: 22:28–24:25

Takeaway Messages

• Do not use SGLT2 inhibitors for inpatient hyperglycemia management due to real and significant risks, especially euglycemic DKA, volume depletion, and infections.
• Insulin (basal-bolus) remains the preferred therapy for most; DPP4 inhibitors may be appropriate in mild cases.
• SGLT2 inhibitors have a role in CHF management in carefully selected, stable patients—typically close to discharge.
• Future research is needed on SGLT2 inhibitor safety and efficacy for in-hospital glycemic control.
• Hospitalization is an opportunity to optimize diabetes management for long-term control.

Shout-out to co-authors:
"Benjamin Cohen was my fellow when we wrote the article ... and Yael Toby Harris … they were really helpful and instrumental in writing our article." (24:32)