From the Guidelines
Oral antidiabetic medications are not recommended for use in hospitalized patients due to their potential limitations and risks, and insulin therapy is preferred for managing hyperglycemia in the inpatient setting. The use of noninsulin antihyperglycemic agents in hospitalized patients is not recommended because of their slow onset of action, risk of hypoglycemia, and potential contraindications, such as acute heart failure or renal or liver failure, which may increase the risk of lactic acidosis 1.
Some of the key limitations of oral antidiabetic medications in the hospital setting include:
- Slow onset of action, which may not allow rapid dose adjustment to meet the changing needs of the acutely ill patient
- Risk of hypoglycemia with insulin secretagogues
- Contraindications to the use of metformin, such as acute heart failure or renal or liver failure, which may increase the risk of lactic acidosis
- Potential to precipitate or worsen heart failure and peripheral edema with thiazolidinediones
In contrast, insulin regimens, typically basal-bolus with correction doses, provide the flexibility needed to manage glycemic control during acute illness, allowing for rapid adjustments as the patient's condition, nutritional status, and medication regimens change during hospitalization 1. Recent studies have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations, but the use of insulin therapy remains the cornerstone of inpatient pharmacological management 1.
Overall, the potential benefits of oral antidiabetic medications in the hospital setting do not outweigh the risks, and insulin therapy is the preferred treatment for managing hyperglycemia in hospitalized patients.
From the Research
Reasons for Not Using Oral Antidiabetic Medications in Hospitals
- Oral antidiabetic medications are not typically used in hospitalized patients due to safety concerns, as noted in a study published in 2020 2.
- The use of oral antidiabetic agents in the hospital setting is limited, and current recommendations suggest insulin as the main glucose-lowering treatment choice 2.
- There is no robust evidence to support the use of metformin, thiazolidinediones, sulfonylureas, and sodium-glucose co-transporter-2 inhibitors in the hospital setting, although some effects on acute outcomes deserve further evaluation 2.
Safety Concerns and Alternative Treatments
- Dipeptidyl peptidase-4 inhibitors have been shown to be a safe and effective alternative to insulin in hospitalized patients with type 2 diabetes, particularly those with mild to moderate hyperglycemia and a stable clinical condition 2.
- A study published in 2007 noted that oral antidiabetic agents, including sulfonylureas and thiazolidinediones, can cause hypoglycemia and weight gain, making them less desirable for use in hospitalized patients 3.
- Another study published in 2021 highlighted the importance of careful use and monitoring of oral antidiabetic medications in elderly patients to minimize adverse events, such as hypoglycemia and cardiovascular events 4.
Risks and Benefits of Oral Antidiabetic Medications
- A review of case reports on metformin, sulfonylureas, and thiazolidinediones in type 2 diabetes mellitus patients found that these medications can cause various adverse effects, including hypoglycemia, weight gain, and cardiovascular events 5.
- A retrospective cohort study published in 2019 compared the risks of all-cause mortality, cardiovascular disease, and severe hypoglycemia among patients with type 2 diabetes on metformin-sulfonylurea dual therapy intensified with dipeptidyl peptidase-4 inhibitor, insulin, or thiazolidinedione, and found that dipeptidyl peptidase-4 inhibitor was associated with the lowest risks of mortality and severe hypoglycemia 6.