Dr Deepak Bhatt on the Importance of In-Hospital Initiation of SGLT2 Inhibitors

Deepak L. Bhatt, MD, MPH, outlines the benefits of starting patients on sodium glucose co-transporter 2 (SGLT2) inhibitors while they are hospitalized.

Results of SOLOIST proved that it was safe to initiate sodium glucose co-transporter 2 (SGLT2) inhibitors in hospitalized patients, Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital Heart & Vascular Center and professor of medicine at Harvard Medical School.


Can you elaborate on the importance of initiating sodium glucose co-transporter 2 inhibitors while patients are still in the hospital?

The in-hospital initiation of SGLT2 inhibitors, I think is really an important concept. We proved in sick patients with acute decompensated heart failure in SOLOIST that it was safe to initiate SGLT2 inhibitors in the hospital. And of course, it was specifically sotagliflozin, but I think that would be a generalizable to all the SGLT2 inhibitors. Now there are specific trials of empagliflozin and dapagliflozin and early initiation of those drugs that are ongoing, so we'll get more data on the topic. But I think the data from SOLOIST are actionable now. I would recommend in patients who are otherwise good candidates for SGLT2 inhibitors that don't have contraindications, when possible, to initiate SGLT2 inhibitors in the hospital.

Now there can be some logistical issues. Is what you have on the inpatient formulary the same as the outpatient formulary that the patient will be on? You want to make sure that there's not going to be awkward switching or so forth of drugs that will need to happen that could lead to errors or dosing errors or stuff like that. But putting that aside as a medical and scientific principle, the data from SOLOIST are in and I think we've shown that it is quite safe in stabilized inpatients—in that case, stabilized from a heart failure admission—to initiate an SGLT2 inhibitor as long as it's done carefully with monitoring I'm not saying we just be cavalier about initiation, what's started in a volume-depleted hypotensive patient. But again, in somebody that's an inpatient heading toward discharge, I think getting on that SGLT2 inhibitor is safe and in the case of patients with diabetes and heart failure, highly efficacious, as we showed in SOLOIST.

Beyond what we showed and studied in the trial, the other important part is if the patient started as an inpatient, I think they're more likely to be adherent, as other studies and other therapeutic classes have shown, because that patient thinks that drug is important. They just came into the hospital sick with heart failure, the doctor started them on an SGLT2 inhibitor, it must be important. And the other part is, as we just showed in SOLOIST, there's a very early benefit. The results were statistically significant in SOLOIST by 28 days. So sure, you can say I'll start the SGLT2 inhibitor in a month or 3 months or 6 months, that's better than not starting it in appropriate patients without contraindications. But if you could have started it in house, as we did in SOLOIST, those events that would have otherwise occurred in that first month, some of them could have been prevented.