Nearly one in four hospitalized 12patients in the U.S. has diabetes. These patients have almost twice the hospital readmission rate as those without diabetes, making it a critical area for hospitalist expertise.1 Ideally, hospitalists should consult with a specialized glucose management team to optimize care, per guidelines from the American Diabetes Association (ADA), but such assistance is not always available.2
Practice standards are evolving in some aspects of diabetes management, especially with respect to certain new medications for type 2 diabetes. In addition to blood glucose control, some of these provide additional benefits for cardiovascular, renal, and/or metabolic health, but questions remain about the best ways to employ them in a hospital setting.2
Dr. Talari
Goutham Talari, MD, an internal medicine hospitalist at AdventHealth in Deland, Fla., said, “Hospitalists have a great opportunity to initiate and continue these medications to improve outcomes like decreased mortality and decreased length of stay, benefits which have been demonstrated in research.”
“Especially for uninsured and underserved patient populations who are only getting their diabetes care in the hospital, we as hospitalists are often the ones starting and adjusting these medications,” said Lily Ackermann, MD, a hospitalist and clinical associate professor of medicine at Thomas Jefferson University in Philadelphia.
Dr. Ackermann
These newer drugs must be employed in the context of overall best practices for diabetes management in the hospital, in which both extreme hyperglycemia and hypoglycemia should be avoided for best patient care, with a target of 100–180 mg/dL (if this can be achieved without significant hypoglycemia).2
Dr. Umpierrez
Guillermo E. Umpierrez, MD, is a professor of medicine in the division of endocrinology at Emory University School of Medicine in Atlanta, and a lead author on the Endocrine Society and ADA guidelines on the management of hyperglycemia in hospitalized adults in non-critical care settings.3 Dr. Umpierrez pointed out that endocrinologists are less available in many hospital settings than in the past. “So, it’s important for hospitalists to be aware of the new drugs and how to improve glycemic control overall, because improving glycemic control reduces complications.”
In the past, Dr. Umpierrez noted, hospitalized patients with diabetes were almost always managed with insulin monotherapy, regardless of their home treatment. This might include some combination of a long- or intermediate-acting basal insulin, bolus (prandial) insulin taken at mealtime, sliding scale insulin (correctional, short-acting insulin), or a continuous IV drip for severe hyperglycemia. This insulin-only approach has the benefit of reducing adverse effects from noninsulin medications during illness and surgery while allowing for flexibility in dosing.
However, this practice is evolving, as reflected in the newest guideline from the ADA, which emphasizes an individualized approach to glycemic management. Dr. Umpierrez noted that some trials have demonstrated that certain outpatient medications may be safely continued during hospitalization in select patients, including metformin and some newer diabetes drugs such as sodium-glucose transport protein-2 (SGLT2) inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors.1,2,4
Dr. Molitch-Hou
The Hospitalist talked with Drs. Umpierrez, Ackermann, and Talari, as well as Ethan Molitch-Hou, MD, a hospitalist and an assistant professor of medicine at the University of Chicago in Chicago, about these newer agents as part of inpatient diabetes management.
SGLT2 Inhibitors
Originally developed to treat type 2 diabetes mellitus, SGLT2 inhibitors block SGLT2 transporters in the renal tubules, preventing the reabsorption of glucose and thereby increasing its excretion through the urine. Four oral agents are currently approved by the U.S. Food and Drug Administration: dapagliflozin, empagliflozin, canagliflozin, and ertugliflozin.5
SGLT2 inhibitors have a low risk of causing hypoglycemia and a very good safety profile, even in frail adults. Importantly, these drugs have significant physiological impacts beyond glucose control, such as decreased fibrosis and tissue remodeling, and they may reduce the risk of major adverse cardiovascular events, heart failure, and chronic kidney disease. This is particularly important given the high rates of these comorbidities in the diabetes population, but they can also sometimes be used in patients with normal HbA1c.5
Dr. Molitch-Hou, part of the inpatient diabetes management workgroup at the University of Chicago in Chicago, said, “We see a mortality benefit for starting SGLT2 inhibitors in multiple studies, like in heart failure and kidney disease, and so now we see a huge population of people coming to the hospital already on these drugs, not just for diabetes.”
Dr. Umpierrez said, “Everybody with heart failure should be considered a candidate for SGLT2 inhibitors, because they decrease hospital readmissions, mortality, and length of hospital stay.” He explained that these agents shouldn’t be employed in a hospital setting solely for glucose control, for which they only provide mild improvement, but to prevent progression of kidney disease and cardiovascular complications. In fact, Dr. Molitch-Hou noted that his hospital will not approve the drugs during hospitalization for diabetes alone but only in the context of one of these other conditions.
Thus, the most recent guidelines from the ADA recommend that for stable patients with type 2 diabetes hospitalized with heart failure, these agents should be initiated or continued from their previous outpatient use (when clinically appropriate) and continued after discharge.2
Dr. Talari pointed to a recent key study that explored the continued use of SGLT2 inhibitors during hospitalization. Continued use of these agents during hospitalization was associated with a 45% decrease in mortality risk compared to patients who were taken off the drug, with no increased risk of acute kidney injury and with a modestly decreased length of stay.6
SGLT2 Inhibitors: Safety Considerations
Dr. Molitch-Hou shared that it’s now common practice at his institution to continue SGLT2 agents in most patients with heart failure, but it’s still important to temporarily hold them in some cases, as per the new ADA guidelines.2
Dr. Ackermann added that these SGLT2 inhibitors have a diuretic effect and carry an increased risk of genitourinary infections. They may need to be held temporarily in patients with volume depletion, acute kidney injury, or acute illness, especially urinary tract infections.
Although rare, a key safety concern for these patients is the development of euglycemic diabetic ketoacidosis (DKA), a potentially fatal complication. Dr. Umpierrez pointed out that despite the name, these patients often still have glucose that is above normal (e.g., 100 mg/dL), although it may be less than the levels traditionally associated with DKA (over 200 mg/dL). Dr. Molitch-Hou advised practitioners to maintain a high index of suspicion, watch out for potential clinical signs, and keep a close eye on the anion gap to make sure that it isn’t widening (due to elevated ketones from DKA).
Due to these risks of DKA or euglycemic DKA, the ADA currently recommends discontinuing SGLT2 inhibitors three to four days before scheduled surgery, as surgical stress, altered oral intake, and dehydration increase the likelihood of euglycemic DKA.2
GLP-1 Receptor Agonists
The glucagon-like peptide-1 (GLP-1) receptor agonists such as exenatide, liraglutide, dulaglutide, and semaglutide are increasingly being prescribed in the outpatient setting for their glycemic control, cardiovascular, and weight loss benefits, with some non-diabetic people pursuing them primarily for the latter role. In some patients, they can be added to SGLT2 inhibitors for additional cardiometabolic benefits.7
Semaglutide is now available in a once-daily oral formulation, but the rest are only available as injections. GLP-1 agents can be combined agents that also act on GIP (glucose-dependent insulinotropic polypeptide) receptors, as in the combined agent, tirzepatide.
The ADA recommends GLP-1 receptor agonists for patients who have type 2 diabetes, obesity, and symptomatic heart failure. The guidelines also recommend GLP-1 inhibitors in patients with type 2 diabetes and advanced chronic kidney disease, as well as type 2 diabetes with obesity and metabolic dysfunction associated steatotic liver disease (MASLD).4
GLP-1 agonists can also help reduce stroke incidence in diabetic patients, and they may play a particularly important role in preventing future heart attacks and stroke in stroke survivors.
“We’re seeing a lot of people come in on GLP-1 medications,” shared Dr. Ackermann, “and there will probably be more and more people coming in on them for things like [MASLD] and obstructive sleep apnea.” Dr. Ackermann noted that many hospitals do not have them on the formulary, and they typically would not be given in an inpatient setting. However, Dr. Talari noted that it may be appropriate to allow patients to bring in their home GLP-1 medications in certain settings, like an extended stay in a rehabilitation facility.
Dr. Umpierrez agrees that starting such agents in the hospital would not usually be desirable, even if practically feasible, because of the risk of gastrointestinal side effects, which occur most frequently at treatment initiation.
However, Dr. Umpierrez pointed out that several of these agents are given weekly, so they continue to work—and carry relevant risks of side effects—if the patient took them prior to their hospital stay. This can sometimes be an issue for patients who need urgent procedures, as these drugs are partly designed to slow gastric emptying, and they might increase the risk of aspiration. This might be an even greater concern in patients with longstanding diabetes who are already at risk of gastroparesis.
This area is a somewhat controversial one, explained Dr. Umpierrez. Although the latest multi-society guidance recommends holding GLP-1 agents for a week before surgery (for once-weekly agents), he noted that several studies have shown that this may not be necessary. It’s important to assess if the patient has any gastrointestinal symptoms, noted Dr. Ackermann, and notify anesthesiology about a patient’s recent use, in case different precautions are needed (e.g., following a “full stomach” protocol).8
Dr. Ackermann added that it’s also important to ask patients about the source of their GLP-1 medications; some patients take compounded GLP-1 medications, which may be of uncertain quality and dose, which they’ve received with little oversight, increasing the risk of symptoms such as intense vomiting. Hospitalists should also be aware of acute cholecystitis and pancreatitis as potential side effects.
DPP-4 Inhibitors
Although not quite as new as the SGLT2 drugs or the oral GLP-1 medications, DPP-4 inhibitors are another important class in terms of evolving management and the use of non-insulin agents to control glucose levels during hospitalization. These include sitagliptin, saxagliptin, linagliptin, and alogliptin.
Per the new ADA guidelines, these agents can be initiated in the hospital for select groups of patients with type 2 diabetes and mild to moderate hyperglycemia, with lower risks of hypoglycemia compared to insulin. Dr. Umpierrez added that for patients with slightly higher blood glucose, e.g., over 200 mg/dL, insulin can be added.2,4
They don’t have specific cardiovascular or renal benefits, but they are very safe, and they are simple and easy to use,” said Dr. Talari, “although saxagliptin and alogliptin might need to be held in people with heart failure.”
Dr. Ackermann added, “I think DPP-4 inhibitors are a great way to control mild hyperglycemia in the hospital, especially for those at risk of hypoglycemia like elderly patients, or those with kidney disease and poor oral intake; it’s another tool which doesn’t have the same risks and patient inconvenience as multiple injections of basal insulin.” She noted that when continued post-discharge, they pose less risk of hypoglycemia compared to some other agents.
Dr. Molitch-Hou also shared that DPP-4 inhibitors in appropriate patients can be a way to reduce the use of sliding scale insulin, which some hospitalists still rely on for the sole management of hyperglycemia in many patients, despite current recommendations to the contrary. Dr. Umpierrez has been arguing against the drawbacks of sole sliding scale insulin use for decades. He noted that the method may be used initially for very mild hyperglycemia, with basal insulin added as needed, but sliding scale insulin should never be used alone for patients with blood glucose of over 200 mg/dL.9
“If practitioners are nervous about starting basal insulin, a DPP-4 inhibitor is a nice sort of incremental step that potentially can be used for glycemic control,” shared Dr. Molitch-Hou.
Discharge Planning and Proactive Management
Beyond direct inpatient management, hospitalists can play an important role in enhancing continuity of care and improving long-term patient outcomes for diabetes patients.
Cost can sometimes be prohibitive with these newer agents, sometimes even for patients who have insurance coverage. Dr. Molitch-Hou noted that at his institution, they regularly check for insurance coverage for SGLT2 inhibitors for appropriate patients with heart failure, trying to initiate necessary prior-authorization processes and clearly communicating this as part of discharge to outpatient care. The prior-authorization process for many medications can take several days, and for these and other reasons, Dr. Ackermann advised starting early on discharge planning and patient education, e.g., for a new potential therapy.
Typically, GLP-1 agents haven’t been prescribed directly at discharge. Dr. Ackermann noted that for a patient who is a good candidate for a GLP-1 drug, it’s important to connect them with providers comfortable prescribing them and who are able to undertake the prior authorization process, since not all primary care doctors are currently doing so.
At Dr. Molitch-Hou’s institution, hospitalists do sometimes start GLP-1 drugs at discharge, particularly for patients with a strong indication, such as diabetic patients who’ve had a stroke. He explained, “In the past, we’ve sometimes been reluctant to start GLP-1 drugs on discharge, but then we miss a lot of patients who could benefit.” His hospital recently changed some of the order sets concerning such patients to help encourage proper prescription of these agents.
Dr. Ackermann pointed out that close communication with outside providers is also helpful for patients previously prescribed GLP-1 drugs. Depending on the medical context and the length of their hospitalization, patients may need to gradually increase their dose again when they begin resuming it as an outpatient.
Dr. Talari noted that medication reconciliation at admission, hospitalization, and discharge presents unique opportunities to assess and revise patients’ home diabetes medications. He shared that it’s important to fully understand the pre-hospitalization picture as well as the full hospital clinical course to make sure that the patients are properly stabilized at discharge and avoid potential readmission.
For example, it’s helpful to look at the patient’s recent hemoglobin A1c to get a sense of how their previous treatment regimen was working, retesting in the hospital if no results from the last three months are available. Dr. Molitch-Hou explained that some patients hospitalized with very high hemoglobin A1c may need to start receiving outpatient insulin, and hospitalists shouldn’t be hesitant to prescribe it at discharge to appropriate patients.
Some patients may need adjustments in the other direction, with deprescribing of previous medications to reduce risks of hypoglycemia. Dr. Ackermann also shared that hypoglycemia post-discharge is a very prevalent problem as patients readjust to their normal life and recover from stress-induced hyperglycemia, and it’s a major cause of hospital readmissions, particularly in the elderly.
Patients sent home on insulin need particularly close follow-up care, as they may need to have their insulin doses reduced post-discharge, and Dr. Ackermann takes a particularly active role in scheduling outpatient care for patients with high hypoglycemia risks. Dr Umpierrez also recommended sending all patients with risk factors for hypoglycemia home with a glucagon prescription to treat severe hypoglycemia if it occurs.
“We have to actively titrate medications according to patients’ hypoglycemic and hyperglycemic risks, their severity of illness, and their hemoglobin A1c, to help decrease their length of stay, decrease mortality, and prevent readmissions,” said Dr. Talari.
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine in Bloomington, Ind., and a freelance medical writer.
References
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2. American Diabetes Association Professional Practice Committee. Standards of care: 16. diabetes care in the hospital: standards of care in diabetes-2025. Diabetes Care. 2025;48(1 Suppl 1):S321-S334. doi: 10.2337/dc25-S016.
3. Korytkowski MT, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2022;107(8):2101- 2128. doi: 10.1210/clinem/dgac278.
4. American Diabetes Association Professional Practice Committee. Standards of care: 9. pharmacologic approaches to glycemic treatment: standards of care in diabetes-2025. Diabetes Care. 2025;48(1 Suppl 1):S181-S206. doi: 10.2337/dc25-S009.
5. Cannarella R, et al. A holistic view of SGLT2 inhibitors: From cardio-renal management to cognitive and andrological aspects. Eur J Intern Med. 2025;138:6-28. doi: 10.1016/j.ejim.2025.06.010.
6. Singh LG, et al. Association of continued use of SGLT2 inhibitors from the ambulatory to inpatient setting with hospital outcomes in patients with diabetes: a nationwide cohort study. Diabetes Care. 2024;47(6):933-940. doi: 10.2337/dc23-1129.
7. Yepes-Cortés CA, et al. Combining GLP-1 receptor agonists and SGLT2 inhibitors in type 2 diabetes mellitus: a scoping review and expert insights for clinical practice utilizing the nominal group technique. Diabetes Ther. 2025;16(5):813-849. doi: 10.1007/s13300-025-01722-x.
8. Kindel TL, et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Clin Gastroenterol Hepatol. 2024:S1542-3565(24)00910-8. doi: 10.1016/j.cgh.2024.10.003.
9. Migdal AL, et al. Inpatient glycemic control with sliding scale insulin in noncritical patients with type 2 diabetes: who can slide? J Hosp Med. 2021;16(8):462-468. doi: 10.12788/jhm.3654.