Evaluate safety of DPP4 inhibitors versus mealtime insulin for glycemic control in non-critically ill-hospitalized patients
Graylon Cross-Penn, Aayush Patel, McKenzie Hodges, Kelly Carter
Piedmont Columbus Regional Midtown – Columbus, GA
Background: The management of hyperglycemia in non-critically ill hospitalized patients with type 2 diabetes is often complex and requires a careful balance between glycemic control and the risk of hypoglycemia. Insulin is a common therapy in the inpatient setting, but it carries a risk of hypoglycemia, particularly in patients with lower baseline insulin requirements. Hypoglycemia leads to adverse clinical outcomes, including cardiovascular events, neurological impairment, and prolonged hospitalizations. These risks highlight the need for alternative approach which maintains glycemic control while minimizing the risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors (DPP-4i) have emerged as a potential alternative for specific populations due to their favorable safety profile, oral route of administration, and tolerability. However, evidence comparing the safety of DPP-4 inhibitors versus insulin in the inpatient setting is limited. This study aimed to address this gap by evaluating the incidence of hypoglycemia and other glycemic outcomes in non-critically ill hospitalized patients receiving either DPP-4 inhibitors or mealtime insulin. The findings may provide critical insights into optimizing glycemic management strategies for hospitalized patients, improving patient outcomes and resource utilization.
Methods: The study reviewed the medical records of non-critically ill patients admitted to Piedmont Hospitals between January 2023 and December 2023. The primary objective was to compare the incidence of hypoglycemia (defined as blood glucose <70 mg/dL) between patients receiving DPP-4 inhibitors and those treated with insulin. Secondary objectives included evaluating the incidence of severe hypoglycemia (BG <50 mg/dL), mean daily blood glucose levels, incidence of hyperglycemia (BG >180 mg/dL), length of hospital stay, total daily insulin requirements, and the number of injections per day.
Patients were included if they were aged 18 years or older, A1C <8% and on outpatient diabetes regimens involving diet alone, oral antidiabetic agents, or insulin therapy of less than 0.5 units/kg/day. Patients were excluded if they were admitted with diabetic ketoacidosis or hyperosmolar state, history of type 1 diabetes, recent glucocorticoid use, ICU admission, history of gallstones, cholecystitis, gallbladder cancer or pancreatitis, blood sugar greater than 400 or less than 70 on admission, patients that underwent surgery, with triglycerides >150 mg/dL, or if they were unable to take oral medications. Statistical analysis was conducted using independent t-tests for primary and secondary outcomes.
Results: In the insulin-only group, there were 14 recorded hypoglycemic events. In the linagliptin with or without insulin group, there were 13 events.
The statistical analysis yielded a p-value of 0.897, indicating no significant difference between the two groups in terms of hypoglycemia risk. The linagliptin and insulin group was much lower with the average daily insulin requirements at 3.94 vs 8.77. This was the only category of the original study that was statistically significant out of the secondary outcomes. The linagliptin group shows significantly higher drug costs—$142.84 compared to $14.57 in the insulin-only group—primarily driven by the high cost of linagliptin ($21/day). When analyzing the linagliptin group only (a subgroup from the linagliptin and correctional insulin) the linagliptin only group out performed the insulin only group, yielding a p-value of 0.029. When further analyzing the linagliptin only subgroup versus the insulin only, it was also statistically significant when comparing average daily blood glucose, number of injections and average daily insulin requirements.
Conclusion: These findings suggest that, in our study population, the addition of a DPP-4 inhibitor did not significantly impact hypoglycemia incidence compared to insulin alone. The total mean cost per patient is nearly 10 times higher in the linagliptin group, highlighting the importance of weighing clinical benefits against financial impact when considering DPP-4 inhibitors in inpatient settings. Standard deviations reflect variability in hospital length of stay. While this chart review provides valuable insights, there are several limitations to consider. First, the data does not represent the United States. Using only linagliptin can be limiting as different DPP4i may have varying efficacy, safety profiles, and patient responses. Additionally, there is differences in diabetes management, which differs across healthcare providers, hospitals, and standard of care groups. These differences in management strategies can impact the consistency of findings and should be considered when interpreting the results. In our analysis, the use of DPP-4 inhibitors was found to be statistically significant when evaluating daily insulin requirements. This suggests that patients on a DPP-4 inhibitor may have different insulin needs compared to those on insulin alone. However, from a cost-effectiveness standpoint, continuing insulin therapy remains a viable and practical option. While our findings provide insight into the potential impact of DPP-4 inhibitors, larger studies with more robust sample sizes are needed to further evaluate their role in non-critically ill hospitalized patients, especially with the linagliptin only group versus insulin only treatment arms.
Contact: graylon.cross-penn@piedmont.org
