Should Sodium-Glucose Cotransporter-2 (SGLT-2) inhibitors be discontinued when a patient is hospitalized?

From the Guidelines

SGLT-2 inhibitors should be continued during hospitalization, unless contraindicated, as they are part of the guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) 1. When considering the management of SGLT-2 inhibitors in hospitalized patients, it's essential to weigh the potential benefits against the risks. The guidelines suggest that preexisting GDMT, which includes SGLT-2 inhibitors for patients with HFrEF, should be continued and optimized during hospitalization to improve outcomes, unless contraindicated 1. Some key points to consider include:

• The risk of complications such as diabetic ketoacidosis (DKA) and genitourinary infections associated with SGLT-2 inhibitors 1
• The potential benefits of SGLT-2 inhibitors in reducing the risk of worsening heart failure, rehospitalization for heart failure, or death 1
• The importance of monitoring and managing blood glucose levels with other medications, such as insulin, during hospitalization
• The decision to restart SGLT-2 inhibitors should be made on a case-by-case basis, considering the patient's clinical stability and recovery. It's crucial to prioritize the patient's overall clinical condition and make decisions based on the most recent and highest-quality evidence available, which in this case supports the continuation of SGLT-2 inhibitors during hospitalization for patients with HFrEF, unless contraindicated 1.

From the FDA Drug Label

Withhold INVOKANA, if possible, in temporary clinical situations that could predispose patients to ketoacidosis. Resume INVOKANA when the patient is clinically stable and has resumed oral intake Consider monitoring for ketoacidosis and temporarily discontinuing JARDIANCE in clinical situations known to predispose to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery)

Stopping SGLT-2 inhibitors when hospitalized is recommended in certain clinical situations that could predispose patients to ketoacidosis, such as surgery or acute illness.

• Key factors to consider when deciding to stop SGLT-2 inhibitors include the patient's clinical stability, oral intake, and risk of ketoacidosis.
• Resume SGLT-2 inhibitors when the patient is clinically stable and has resumed oral intake 2, 3.

From the Research

Stopping SGLT-2 Inhibitors During Hospitalization

• The decision to stop SGLT-2 inhibitors during hospitalization is a topic of ongoing debate, with some studies suggesting that the benefits of these medications may outweigh the risks in certain situations 4.
• However, other studies have raised concerns about the safety of SGLT-2 inhibitors in the hospital setting, particularly with regards to the risk of diabetic ketoacidosis (DKA) and other adverse events 5.
• A review of the literature found that hospitalized patients treated with SGLT-2 inhibitors were at increased risk of DKA, euglycemic DKA, hypovolemia, and urinary tract infections 5.
• In contrast, another study found that the risk of DKA associated with SGLT-2 inhibitors was low, and that the benefits of these medications in terms of cardiovascular and kidney outcomes may outweigh the risks 4.
• The American College of Endocrinology and the American Association of Clinical Endocrinologists recommend avoiding SGLT-2 inhibitors for the inpatient management of hyperglycemia due to the increased risk of adverse events 5.

Considerations for SGLT-2 Inhibitor Use in the Hospital Setting

• Physicians should carefully consider the risks and benefits of SGLT-2 inhibitors in the hospital setting, taking into account the individual patient's medical history and current condition 6.
• The use of SGLT-2 inhibitors in the hospital setting may be justified in certain situations, such as in patients with congestive heart failure or chronic kidney disease, but should be started close to or at the time of discharge 5.
• Further research is needed to fully understand the risks and benefits of SGLT-2 inhibitors in the hospital setting, and to develop evidence-based guidelines for their use in this context 4, 7.
• A meta-analysis of randomized controlled trials found that the risk of DKA associated with SGLT-2 inhibitors was negligible when the drug was properly prescribed 8.