Noninsulin antihyperglycaemic drugs for hospitalised adults

The decision to continue usual noninsulin antihyperglycaemic drugs for hospitalised adults with diabetes must be made on an individual basis. Consideration should be given to the severity of illness, the degree of severity of the hyperglycaemia, and the potential adverse effects of the drug. For considerations for use of noninsulin antihyperglycaemic drugs in hospitalised adults, see Considerations for use of noninsulin antihyperglycaemic drugs in hospitalised adults.

Hyperglycaemia occurring in hospitalised adults is best managed with a multiple daily injection (basal–bolus) insulin regimen (see Multiple daily injection (basal–bolus) insulin regimen).

Table 1. Considerations for use of noninsulin antihyperglycaemic drugs in hospitalised adults
[NB1]
Considerations for use of noninsulin antihyperglycaemic drugs in hospitalised adults. metformin SGLT2 inhibitors sulfonylureas GLP-1 receptor agonists DPP-4 inhibitors thiazolidinediones acarbose
metformin
can cause adverse effects in patients with severe kidney impairment (chronic kidney disease stage 3 or more, or creatinine clearance less than 40 mL/min) withhold metformin if these patients: are unwell and at risk of further deterioration in kidney function are undergoing surgical or diagnostic procedures that use radiocontrast
SGLT2 inhibitors
associated with an increased risk of genitourinary infections, dehydration, and development of DKA. The risk of DKA associated with SGLT2 inhibitors is particularly high in hospitalised patients because some predisposing factors are more common in this setting—for example, an increased requirement for insulin during an infection; intermittent fasting (eg for a procedure); or poor oral intake to reduce the risk of DKA, withhold SGLT2 inhibitors in patients: undergoing a procedure (see Preprocedural management of noninsulin antihyperglycaemic drugs for adults with type 2 diabetes) who have a substantially decreased carbohydrate intake (eg fasting, poor oral intake) if the SGLT2 inhibitor is not withheld, consider daily capillary blood ketone monitoring, regardless of whether the patient is unwell or having a procedure if the SGLT2 inhibitor is withheld, ensure it is restarted on or after discharge, once the patient is eating and drinking normally and kidney function has returned to baseline
sulfonylureas
can cause hypoglycaemia, especially if a patient is not eating normally or is intermittently fasting for procedures and investigations
GLP-1 receptor agonists
can exacerbate nausea, vomiting and anorexia
DPP-4 inhibitors
can exacerbate heart failure (saxagliptin, alogliptin)
thiazolidinediones
can cause fluid retention and exacerbate heart failure
acarbose
can cause gastrointestinal adverse effects. Glucose must be used if acarbose-induced hypoglycaemia occurs; sucrose is ineffective
Note: DKA = diabetic ketoacidosis; DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; SGLT2 = sodium-glucose co-transporter 2 NB1: See Approach to antihyperglycaemic treatment for adults with type 2 diabetes for information on noninsulin antihyperglycaemic drugs.