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.