Post-Transplant Diabetes Mellitus: Recent Developments in Pharmacological Management of Hyperglycemia.

The management of solid organ transplantation is rapidly evolving, and post-transplant diabetes mellitus (PTDM) is increasingly common and is a barrier to transplant success, adversely impacting infection rates, allograft survival, cardiovascular disease, quality of life (QOL), and overall mortality. Currently, the management of PTDM relies primarily on intensified insulin therapy. However, emerging studies report that several noninsulin glucose-lowering agents are safe and effective in improving metabolic control and enhancing treatment adherence. More importantly, their use in PTDM can potentially transform the long-term management of these complex patients as some glucose-lowering agents may provide additional benefits to glycemic control. For instance, the newer agents glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors, may offer cardiorenal protection, and the older agent pioglitazone, treatment for nonalcoholic fatty liver disease (NAFLD). This review will focus on the pharmacological management of PTDM and the emerging evidence for noninsulin glucose-lowering agents in this population. Evidence from observational studies, randomized controlled trials, and meta-analyses. PTDM adversely affects the outcomes of infection, organ survival, cardiovascular events, and mortality. Insulin therapy has been the drug of choice but is associated with weight gain and hypoglycemia. In contrast, non-insulin agents appear safe and may provide additional benefits, such as cardiorenal protection with SGLT-2 inhibitors and GLP-1 RA, and cardiometabolic benefits with pioglitazone to patients undergoing solid-organ transplantation. Optimal care of patients with PTDM requires close monitoring and the early involvement of the endocrinologist as part of a multidisciplinary team. Noninsulin glucose-lowering agents will likely play an increasing role. Long-term, controlled studies are urgently needed before they can be more broadly recommended in this setting.

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