Cardiovascular Safety of Antidiabetic Drugs in the Hospital Setting

Patients with diabetes and/or stress hyperglycemia requires good glycemic control in the hospital setting, often requiring the use of glucose-lowering therapy. Standard-of-care dictates that non-insulin therapy be discontinued, with insulin therapy initiated using a basal-bolus approach. However, insulin is associated with a high risk for hypoglycemia and medical errors. Alternatives to insulin are needed in the inpatient setting, but the cardiovascular (CV) safety of non-insulin therapy is a concern.

Most studies of antidiabetic drugs have been performed in the outpatient setting, and except for insulin therapy, trials in the inpatient setting have been insufficient to establish CV safety. Randomized controlled trials support the safety of insulin with more moderate glycemic control in the hospital, when hypoglycemia is minimized. Two recent multicenter randomized controlled clinical trials support the safety of sitagliptin, a dipeptidylpeptidase-4 inhibitor (DPP4i), in hospitalized patients, although the sample sizes were likely too small to detect CV events. Small trials suggest a possible CV benefit of glucagon-like peptide-1 receptor agonist therapy. A paucity of evidence and presence of side effects and cautions with insulin secretagogues, sodium glucose-co-transporter-2 inhibitors, and metformin preclude their routine use in the hospital setting. Available evidence is inadequate to evaluate the CV safety of most antidiabetic drug classes in the hospital setting. However, preliminary data from randomized clinical trials suggest the potential safety of the DPP4i sitagliptin.