The management of hyperglycemia in noncritically ill, hospitalized patients with diabetes
mellitus is mainly based on insulin therapy . This usually consists of one dose of
long-acting basal insulin and three doses of rapid-acting premeal bolus insulins
(basal-bolus insulin). Basal-bolus insulin therapy is, however, labor intensive,
requiring multiple insulin injections per day and multiple daily blood glucose checks.
The use of oral antidiabetic medications has generally not been recommended for patients
admitted to the hospital. This is because of the lack of safety and efficacy . data, and
concerns about hypoglycemia. Oral medication usually has a slow onset of action that
might preclude daily dose adjustments and have considerable interactions with
concomitantly administered drugs. Oral antidiabetic medications are also withheld during
hospitalization because of several safety concerns related to altered pharmacokinetics in
cases of end-stage organ disease, such as renal or liver failure. Dipeptidyl peptidase-4
inhibitors (sitagliptin and linagliptin) have been studied for the treatment of
hospitalized patients in the noncritical care setting. Complementary to insulin therapy,
these drugs improved glycemia and were found to be safe. Sodium-glucose cotransporter
type 2 (SGLT2) inhibitors are another class of oral glucose-lowering medication that is
increasingly being used in patients with T2D, due to multiple pleiotropic efects . These
drugs reduce cardiovascular mortality, especially by reducing the risk of heart failure,
and also improve renal outcomes . Recently, two randomized controlled trials demonstrated
improvement in several cardiac outcomes when SGLT2 inhibitors (empaglifozin and
dapaglifozin) were initiated in patients admitted for acute heart failure, with or
without diabetes .This trial aimed to examine the efficacy and safety of Empagliflozin in
Hopitalised patients in comparison to Sitagliptin.
Hyperglycaemia is a common and serious health-care problem in hospitals, reported in
approximately 30% of patients in general medicine and surgery with and without a history
of previous diabetes mellitus..Extensive evidence from observational and randomised
clinical studies in patients admitted to hospital indicates that hyperglycaemia, in
patients both with and without diabetes, is a predictor of poor outcome.In such patients,
hyperglycaemia is associated with prolonged hospital stay, increased incidence of
infections, hospital complications, and death. Improvement in glycaemic control with
insulin therapy has been shown to reduce the risk of infection and complications in
patients in hospital critical-care units and in patients admitted to general surgical and
medical services. Although insulin therapy is the standard of care in hospitals, it is a
source of medication errors and increased risk of hypoglycemia. An analysis of medication
errors between 2006 and 2008 revealed that insulin was the drug with the greatest number
of medication errors in hospitals. Hypoglycemia in the hospital has been associated with
adverse cardiovascular outcomes such as prolonged QT intervals, ischemic
electrocardiogram changes/angina, arrhythmias, sudden death, and increased
inflammation..In addition, insulin-induced hypoglycemia is associated with increases in
C-reactive protein and proinflammatory cytokines (TNF-α, interleukin-1β, IL-6, and
interleukin-8), markers of lipid peroxidation, ROS, and leukocytosis.. The use of oral
antidiabetic agents is not recommended in hospitals because few data are available
regarding their safety and efficacy in the inpatient setting. Major limitations to the
use of oral agents in the hospital include their side effect profiles and slow onset of
action, which does not allow for rapid attainment of glycemic control or dose adjustments
to meet the changing needs of acutely ill patients. Sodium glucose co-transporter 2
(SGLT-2) inhibitors are a new class of oral antidiabetic medications that increase
urinary glucose excretion by reducing renal glucose reabsorption in the proximal
convoluted tubules. Canaglifozin and dapaglifozin are the two available drugs approved by
the U.S. Food and Drug Administration for management of type 2 diabetes. Both agents are
effective in reducing A1C by ~ 0.6-0.8%, with a low risk of hypoglycemia. A recently
published, randomized pilot study assessed the safety and efficacy of SGLT2 inhibitor
Dapagliflozin for the inpatient management of type 2 diabetes(37). In this study done in
hospitalized patients with T2D admitted for cardiac surgery, treatment with dapaglifozin
10 mg once a day plus basal-bolus insulin or basal-bolus insulin regimen alone in the
early postoperative period resulted in similar glycemic control. There was a rapid
improvement in glycemic control in both groups, without signifcant diferences in mean
daily blood glucose, number and percentage of blood glucose values within the target of
70-180 mg/dL, total daily insulin doses and number of daily insulin injections. As the
use of dapaglifozin complementary to basal-bolus insulin did not reduce insulin dose or
the number of insulin injections per day, therefore dapaglifozin lacks glycemic efficacy
in hospitalized cardiac surgery patients. A recently published, randomized pilot study
assessed the safety and efficacy of the DPP-4 inhibitor sitagliptin for the inpatient
management of type 2 diabetes(31).In this trial, patients treated with diet, oral
antidiabetic agents, or a low daily insulin dose (≤ 0.4 units/kg/day) were randomized to
sitagliptin alone or in combination with low-dose insulin glargine or to a basal-bolus
insulin regimen plus supplemental doses of insulin lispro. Glycemic control improved
similarly in all treatment groups. The trial met the non-inferiority threshold for the
primary endpoint of differences between the sitagliptin-basal and basal-bolus groups for
mean daily blood glucose concentrations. Of patients with type 2 diabetes admitted to
general medicine and surgery services in hospital, treatment with a daily dose of
sitagliptin and basal insulin or with a basal bolus regimen resulted in similar glycaemic
control and frequency of complications.