This session was presented by Niti Patel, MD, PharmD, assistant professor of medicine at Northwestern Feinberg School of Medicine in Chicago, and Thomas Chen, MD, PharmD, assistant professor of medicine and co-director of the personalized therapeutics clinic at UChicago Medicine in Chicago. Both presenters brought unique perspectives as former pharmacists who transitioned into hospital medicine, and each highlighted emerging pharmacologic therapies directly impacting inpatient medicine.
The session first focused on terlipressin, the first U.S. Food and Drug Administration (FDA)-approved medication for use in patients with hepatorenal syndrome (HRS). As a vasopressin analog, terlipressin reduces splanchnic vasodilation and increases renal perfusion. In the CONFIRM trial, terlipressin plus albumin demonstrated higher rates of HRS reversal than placebo (32% versus 17%).1 Other trials indicate that it reduced the need for renal replacement therapy. Also, compared to midodrine-octreotide (which is not FDA-approved), it doubled HRS-acute kidney injury reversal and improved survival outcomes overall.
Major adverse effects are a concern: death due to respiratory failure occurred in 11% of the terlipressin group compared to 2% in the placebo group, so it is generally contraindicated in patients with significant hypoxemia. Also, patients with serum creatinine greater than 5 mg/dL are unlikely to benefit from this medication. Despite these potential barriers, terlipressin is an important therapeutic option and may prove beneficial, particularly when initiated early in patients without hypoxemia, with less advanced renal dysfunction, and in consultation with hepatology.
Vonoprazan, a potassium-competitive acid blocker, was discussed as an alternative to proton pump inhibitors (PPIs). It has demonstrated rapid, strong, and sustained acid suppression, and unlike PPIs, it does not require acid for activation or specific meal timing to increase potency, resulting in faster, more sustained elevation of gastric pH and better nocturnal control of pH.
Clinical trials demonstrated additional benefits of vonoprazan. Compared to lansoprazole, vonoprazan for severe esophagitis showed an improvement of 70% versus 53% at two weeks and 92% versus 72% at eight weeks and was superior in maintaining healing. It is superior in clarithromycin-resistant strains. It is also noninferior in gastrointestinal bleeding and has a similar side effect profile to PPIs.
A brief comparison of apixaban and rivaroxaban highlighted emerging randomized evidence suggesting lower clinically relevant bleeding with apixaban, supporting its use in patients with higher bleeding risk when clinically appropriate.
Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, was presented as a medication with proven cardiorenal benefit. Notably, the FIDELIO-DKD trial demonstrated reductions in kidney failure and improved cardiovascular outcomes in patients with type 2 diabetes and advanced chronic kidney disease (CKD) who are already optimized on renin-angiotensin system blockade (with ACE inhibitors or ARBs).2 More recently, FINEARTS-HF, a large double-blind randomized trial in patients with symptomatic heart failure with preserved ejection fraction, demonstrated a significant lowering of the composite outcome of worsening heart failure events and cardiovascular death compared to placebo.3
Finerenone’s effects on blood pressure are minimal, and the main consideration for monitoring is potassium, as hyperkalemia can become a concern. Finerenone is currently FDA-approved for reducing the risk of kidney disease progression and cardiovascular events in patients with CKD associated with type 2 diabetes, and for reducing the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visits in patients with heart failure with left ventricular ejection fraction equal to or greater than 40%.
Intravenous fosfomycin is an emerging option for complicated urinary tract infections (cUTI), particularly those caused by multidrug-resistant organisms. The ZEUS trial demonstrated noninferiority of fosfomycin to piperacillin-tazobactam, with similar clinical cure rates (90.8% versus 91.6%).4 However, its use is limited by its high sodium content and potential adverse reactions, including hypokalemia, hypophosphatemia, prolonged QT, and neutropenia. Current Infectious Diseases Society of America guidelines note that it is not first-line for empiric complicated urinary tract infection treatment due to lack of availability, difficulty with susceptibility testing, and concern for adverse events, but can be an alternative consideration.5
Several non-statin lipid-lowering agents can be used to achieve goals in patients at very high risk for atherosclerotic cardiovascular disease. For these patients, with a goal low-density lipoprotein (LDL) of 55 mg/dL, high-intensity statins remain first-line. If goals are not achieved despite optimizing statins, then ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab, alirocumab) should be considered. PCSK9 inhibitors can provide substantial LDL reduction but are administered via injection, are costly, and often require prior authorizations. Another option can be inclisiran, which is an injectable small-interfering ribonucleic acid that prevents the production of the PCSK9 protein. Inclisiran can be used in patients with adherence issues as it can be dosed twice a year and can decrease LDL by 50% if used alongside statins. Lastly, bempedoic acid, an oral option, can provide a modest LDL reduction (15% to 25%). Though it has a lower risk of myopathy compared to statins, it can increase the risk of hyperuricemia and tendon rupture and cause mild liver enzyme elevations.
Finally, GLP-1 receptor agonists were featured as part of the arsenal of expanding therapies with cardiovascular, metabolic, and renal benefits. More FDA-approved oral options are emerging in more convenient and accessible forms. Notably, the OASIS 1 and 4 trials saw significant weight reduction in both the 50-mg and 25-mg formulations of oral semaglutide, respectively.6,7
Oral semaglutide has low bioavailability and requires strict administration conditions: it must be taken at least 30 minutes before food, drink, or other medications with water. Despite these dosing constraints, oral formulations are comparable to subcutaneous formulations in terms of weight loss, hemoglobin A1c reductions, and side effect profiles. In heart failure with preserved ejection fraction, this drug class improves functional status and quality of life and reduces the composite of cardiovascular death and worsening heart failure events.
Hospitalists must consider GLP-1 receptor agonists in perioperative settings. These medications are often recommended to be held prior to surgery, with weekly-dosed medications held one week prior and daily dosed medications held the day of. Clear liquids for 24 hours prior to surgery are also recommended for patients at high risk for aspiration. However, personalized guidance should be considered, and close collaboration with anesthesia is recommended.
Dr. Hwang
Dr. Hwang is an assistant professor of medicine in the division of hospital medicine at Emory University School of Medicine and a hospitalist at Emory University Hospital Midtown, both in Atlanta.
References
- Wong F, et al. Terlipressin plus albumin for the treatment of type 1 hepatorenal syndrome. N Engl J Med. 2021;384:818-828. doi:10.1056/NEJMoa2008290.
- Bakris GL, et al. Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-2229. doi:10.1056/NEJMoa2025845.
- Pabon MA, et al. Finerenone in heart failure with improved ejection fraction. JAMA Cardiology. 2025;10(7):740-745. doi:10.1001/jamacardio.2025.1101.
- Kaye KS, et al. Fosfomycin for injection (ZTI-01) versus piperacillin-tazobactam for the treatment of complicated urinary tract infection including acute pyelonephritis: ZEUS, a phase 2/3 randomized trial. Clin Infect Dis. 2019;69(12):2045-2056. doi:10.1093/cid/ciz181.
- Infectious Diseases Society of America. Complicated urinary tract infections cUTI: clinical guidelines for treatment and management. IDSA website. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections/. Published July 17, 2025. Accessed June 10, 2026.
- Knop FK, et al. Oral semaglutide 50 mg taken once per day in adults with overweight or obesity (OASIS 1): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2023;402(10403):705-719.
- Wharton, S., et al. Oral semaglutide at a dose of 25 mg in adults with overweight or obesity. NEJM. 2025;393(11):1077-1087. doi:10.1056/NEJMoa2500969.