https://www.aafp.org/afp/2017/1115/p648.html

Glucose Management in Hospitalized Patients

• CHARLES KODNER, MD; LAURIE ANDERSON, MD; and KATHERINE POHLGEERS, MD, University of Louisville School of Medicine, Louisville, Kentucky

• Am Fam Physician. 2017 Nov 15;96(10):648-654.

• Some experts and guidelines recommend stopping oral diabetes medications while patients are hospitalized.9–12 In particular, these guidelines recommend stopping metformin at the time of admission because of inpatient factors that can increase the risk of renal or hepatic failure. However, oral diabetes medications may have important nonglycemic benefits and may reduce the risk of widely fluctuating blood glucose levels. In general, diabetes medications taken at home should be reviewed carefully for possible contraindications and continued if possible; they should be held during hospitalization only if necessary.4,12,13

  1. The use of metformin in hospitalized patients with diabetes is an evolving topic with uncertain risks and benefits, and published guidelines do not always reflect the most current evidence. Uncertainties related to metformin use in the hospital setting pertain to the risk of lactic acidosis, particularly in patients who need imaging studies that use contrast media. Although metformin has a theoretical risk of inducing lactic acidosis, a Cochrane review found no cases of fatal or nonfatal lactic acidosis in 59,321 patient-years of metformin use

     1. https://pubmed.ncbi.nlm.nih.gov/20393934/ Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus

  2. In clinically stable patients, there is no good evidence to support routinely stopping metformin at admission. However, because the risk of lactic acidosis increases with declining renal function, metformin dosage reduction is recommended if the estimated glomerular filtration rate is 30 to 45 mL per minute per 1.73 m², and metformin should be discontinued if it is less than 30 mL per minute per 1.73 m².

  3. Because contrast media–induced nephropathy can decrease renal function and theoretically cause lactic acidosis in patients receiving metformin, the medication is typically stopped before imaging procedures using contrast media and restarted 48 hours after the procedure if renal function remains stable. Some current guidelines indicate that metformin can be used in selected stable patients in the hospital,12 whereas others still recommend holding this medication around the time of procedures using contrast media.18 However, the evidence supporting these recommendations is poor and inconsistent. In the absence of clear evidence, physicians should carefully assess the risks and benefits in individual patients.18

  4. There are many other factors that increase the risk of lactic acidosis in hospitalized patients, such as dehydration, severe heart failure, renal failure, other causes of metabolic acidosis, and severe hepatic impairment.19–21 These factors appear to be stronger predictors of the development of acidosis than metformin use, and the benefits of metformin appear to significantly outweigh its rare risks. If metformin is stopped when patients are hospitalized, it is important that the medication be resumed at the time of discharge, assuming there are no contraindications such as worsened renal function since admission.

  5. Evidence and experience with the incretin-based therapies in the inpatient setting is evolving. Glucagon-like peptide 1 receptor agonists may result in nausea and therefore are not ideal in acutely ill patients and should be avoided when nutritional intake is reduced. Regarding the dipeptidyl peptidase-4 (DPP-4) inhibitor class of drugs, a small pilot study including 90 patients taking sitagliptin (Januvia) alone, sitagliptin plus basal insulin, or basal insulin plus corrective insulin at mealtimes found no differences in blood glucose control or hypoglycemia among groups. However, the study was underpowered and requires verification by larger studies in other populations

https://diabetesjournals.org/care/article/44/Supplement_1/S211/30817/15-Diabetes-Care-in-the-Hospital-Standards-of

STANDARDS OF CARE| DECEMBER 04 2020

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021

American Diabetes Association

• Critical Care Setting

  • In the critical care setting, continuous intravenous insulin infusion is the most effective method for achieving glycemic targets. Intravenous insulin infusions should be administered based on validated written or computerized protocols that allow for predefined adjustments in the infusion rate, accounting for glycemic fluctuations and insulin dose

• Noncritical Care Setting

  • In most instances, insulin is the preferred treatment for hyperglycemia in hospitalized patients. However, in certain circumstances, it may be appropriate to continue home regimens including oral glucose-lowering medications (41). If oral medications are held in the hospital, there should be a protocol for resuming them 1–2 days before discharge. For patients using insulin, recent reports indicate that inpatient use of insulin pens is safe and may be associated with improved nurse satisfaction compared with the use of insulin vials and syringes (42–44). Insulin pens have been the subject of an FDA warning because of potential blood-borne diseases; the warning “For single patient use only” should be rigorously followed (45).

  • Noninsulin Therapies

  • The safety and efficacy of noninsulin glucose-lowering therapies in the hospital setting is an area of active research (57,58). Several recent randomized trials have demonstrated the potential effectiveness of glucagon-like peptide 1 receptor agonists (-glutide) and dipeptidyl peptidase 4 inhibitors (-gliptin) in specific groups of hospitalized patients (59–62). However, an FDA bulletin states that providers should consider discontinuing saxagliptin and alogliptin in people who develop heart failure (63).

  • Sodium–glucose cotransporter 2 (SGLT2) inhibitors (-flozin) should be avoided in cases of severe illness, in patients with ketonemia or ketonuria, and during prolonged fasting and surgical procedures (4). Until safety and effectiveness are established, SGLT2 inhibitors are not recommended for routine in-hospital use. Furthermore, the FDA has recently warned that SGLT2 inhibitors should be stopped 3 days before scheduled surgeries (4 days in the case of ertugliflozin).