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Experts to weigh starting SGLT2 inhibitors and GLP-1 receptor agonists in the hospital


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Have your patients with type 2 diabetes and cardiovascular or renal problems who are hospitalized started sodium-glucose cotransporter-2 (SGLT2) inhibitors and/or glucagon-like peptide-1 (GLP-1) receptor agonists? For many clinicians, the answer is no, despite the proven cardiovascular and renal benefits provided by these two drug classes.

Jennifer Green, MD
Jennifer Green, MD

“The ADA guidelines state that these are high-priority medications to improve outcomes in patients who have or who are at high risk for cardiovascular and kidney complications of type 2 diabetes,” said Jennifer Green, MD, Professor of Medicine at Duke University. “Hospitalizations represent an important juncture at which patients’ risk reduction regimens can be reassessed and modified to incorporate these sorts of guideline recommendations. But adoption of these agents in general is quite slow.”

Dr. Green will discuss some of the factors that may give clinicians second thoughts about initiating the two drug classes during the session Are We There Yet? Initiating SGLT2 Inhibitors and/or GLP-1 RAs in the Inpatient Cardiovascular Setting. Sandeep Das, MD, MPH, Associate Professor of Medicine at the University of Texas Southwestern Medical Center, will discuss the benefits of initiating treatment during the one-hour mini-symposium, which will begin at 12:45 p.m. ET on Friday, June 25.

One concern is the lack of data on SGLT2 inhibitors and GLP-1 receptor agonists in the inpatient setting.

“Even if you have patients who have the sort of cardiovascular or kidney-related issues these agents address, there are a lot of questions about starting them in hospital,” Dr. Green noted. “It’s the absence of data relating to the safety and tolerability of use in the hospital setting that raises questions.”

And for all their proven cardiovascular and kidney benefits, both agents come with important cautions, she added.

SGLT2 inhibitors are associated with an increased risk of euglycemic diabetic ketoacidosis in individuals with type 2 diabetes. To reduce this risk, the Food and Drug Administration recommends stopping SGLT2 inhibitor treatment prior to surgeries or other major procedures, and also during periods of illness with reduced oral intake.

GLP-1 receptor agonists can have fairly significant gastrointestinal effects, especially when initiated or up-titrated, Dr. Green added.

“These are both potential obstacles to use,” she said. “And I would note that most of the cardiovascular or kidney outcomes trials in which these agents were studied really looked at patients in whom the drugs were initiated in the outpatient setting. So initiating them in hospital is a little bit of an extrapolation from the use with which we are most familiar.”

Uptake of both agents is low in all settings, Dr. Green noted, not just in hospitals. And for some patients, there could be clear advantages to starting inpatient treatment.

A patient with diabetes who is hospitalized with a new heart failure diagnosis or for a heart failure exacerbation could be an ideal candidate to initiate treatment, she said. Not only is there significant clinical benefit, but starting a new drug while hospitalized can help emphasize the importance of continuing treatment at home.

“These two agents are cutting edge in cardio-renal risk reduction in patients with type 2 diabetes, and we’re not doing a particularly good job of implementing effective therapies in clinical practice with them,” Dr. Green said. “Improving use in hospitals represents one potential path forward to remedy that situation.”

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