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Zughaib MT, Patel K, Leka M, Affas S. Self-Induced Euglycemic Diabetic Ketoacidosis: When to Stop the Drip. Cureus 2022; 14:e21768. [PMID: 35251838 PMCID: PMC8890007 DOI: 10.7759/cureus.21768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/19/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a well-known, serious complication that many patients with type 1 and 2 diabetes face due to either a relative or absolute insulin deficiency. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have gained increased popularity due to their diabetic, cardiovascular, and renal benefits. An associated complication of SGLT2 inhibitors is euglycemic DKA. A 56-year-old male with a history of type 2 diabetes mellitus and peripheral neuropathy presented with right foot pain secondary to a diabetic foot ulcer. The ulcer was present for one year, but the patient noticed increased pain and purulent discharge over the three days prior to presentation. While being treated inpatient for the foot ulcers, the patient repeatedly refused to receive standard hospital diabetes management of insulin injections. He instead insisted to take his home medications against medical advice, which were metformin and Glyxambi® (empagliflozin/linagliptin, Boehringer Ingelheim, Ingelheim am Rhein, Germany). His diabetic foot ulcer was medically managed with IV antibiotics. On day 4 of admission, his anion gap increased to 23 mEq/L, and serum bicarbonate (CO2) decreased to 8 mEq/L, raising concerns of diabetic ketoacidosis. His glucose was 141 mg/dL, his beta-hydroxybutyrate was high at 5.5 mmol/L. An arterial blood gas (ABG) test demonstrated anion gap metabolic acidosis with secondary respiratory alkalosis. A urinalysis demonstrated glucose 1000 mg/dL and ketones of 150 mg/dL. The patient was diagnosed with euglycemic DKA. Due to the patient having normal glucose levels, an insulin drip and a 5% dextrose with 0.45% normal saline drip were started. Basic metabolic profiles were ordered every four hours, with glucose checks every hour. Once the anion gap was closed and his urinary ketones disappeared, the patient transitioned to subcutaneous insulin. He was able to be discharged home with basal subcutaneous insulin and metformin with instructions to avoid SGLT2 inhibitors in the future. Unfortunately, there are currently no guidelines from endocrinology or internal medicine societies regarding the management of euglycemic DKA. As the typical DKA diagnostic criteria of elevated blood glucose level are not present, it is easy to overlook euglycemic DKA. As these SGLT2 inhibitors become more prevalent, careful monitoring of all potential side effects as well as the contraindications are prudent to successful management of complex disease states.
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52
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Preoperative optimization of diabetes. Int Anesthesiol Clin 2022; 60:8-15. [PMID: 34897217 DOI: 10.1097/aia.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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53
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Sloan G, Alam U, Selvarajah D, Tesfaye S. The Treatment of Painful Diabetic Neuropathy. Curr Diabetes Rev 2022; 18:e070721194556. [PMID: 34238163 DOI: 10.2174/1573399817666210707112413] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/18/2021] [Accepted: 03/08/2021] [Indexed: 11/22/2022]
Abstract
Painful diabetic peripheral neuropathy (painful-DPN) is a highly prevalent and disabling condition, affecting up to one-third of patients with diabetes. This condition can have a profound impact resulting in a poor quality of life, disruption of employment, impaired sleep, and poor mental health with an excess of depression and anxiety. The management of painful-DPN poses a great challenge. Unfortunately, currently there are no Food and Drug Administration (USA) approved disease-modifying treatments for diabetic peripheral neuropathy (DPN) as trials of putative pathogenetic treatments have failed at phase 3 clinical trial stage. Therefore, the focus of managing painful- DPN other than improving glycaemic control and cardiovascular risk factor modification is treating symptoms. The recommended treatments based on expert international consensus for painful- DPN have remained essentially unchanged for the last decade. Both the serotonin re-uptake inhibitor (SNRI) duloxetine and α2δ ligand pregabalin have the most robust evidence for treating painful-DPN. The weak opioids (e.g. tapentadol and tramadol, both of which have an SNRI effect), tricyclic antidepressants such as amitriptyline and α2δ ligand gabapentin are also widely recommended and prescribed agents. Opioids (except tramadol and tapentadol), should be prescribed with caution in view of the lack of definitive data surrounding efficacy, concerns surrounding addiction and adverse events. Recently, emerging therapies have gained local licenses, including the α2δ ligand mirogabalin (Japan) and the high dose 8% capsaicin patch (FDA and Europe). The management of refractory painful-DPN is difficult; specialist pain services may offer off-label therapies (e.g. botulinum toxin, intravenous lidocaine and spinal cord stimulation), although there is limited clinical trial evidence supporting their use. Additionally, despite combination therapy being commonly used clinically, there is little evidence supporting this practise. There is a need for further clinical trials to assess novel therapeutic agents, optimal combination therapy and existing agents to determine which are the most effective for the treatment of painful-DPN. This article reviews the evidence for the treatment of painful-DPN, including emerging treatment strategies such as novel compounds and stratification of patients according to individual characteristics (e.g. pain phenotype, neuroimaging and genotype) to improve treatment responses.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine and the Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Liverpool University Hospital, NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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54
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Gomez-Sanchez CM, Wu BX, Gotts JE, Chang RW. Euglycemic diabetic ketoacidosis following major vascular surgery is a new item on the differential for postoperative acidosis. J Vasc Surg Cases Innov Tech 2021; 7:778-780. [PMID: 34816071 PMCID: PMC8591455 DOI: 10.1016/j.jvscit.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
New pharmacologic advances in the treatment of diabetes include SGLT-2 inhibitors, which have been demonstrated in randomized-controlled clinical trials to reduce overall and cardiac-specific mortality and slow progression of chronic kidney disease. Euglycemic diabetic ketoacidosis is a rare but life-threatening complication associated with the use of SGLT-2 inhibitors. Here we describe a case of severe euglycemic diabetic ketoacidosis after lower extremity bypass in a patient taking an SGLT-2 inhibitor. Awareness of this potential complication is essential as these novel agents are increasingly used in patients with cardiovascular disease.
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Euglycemic Diabetic Ketoacidosis in a Sedated Patient after Coronary Artery Bypass Grafting: A Case Report and Literature Review. Case Rep Med 2021; 2021:2086520. [PMID: 34840578 PMCID: PMC8616646 DOI: 10.1155/2021/2086520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/15/2021] [Indexed: 01/24/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (EDKA) is a rare and serious adverse effect of sodium-glucose cotransporter 2 inhibitors (SGLT-2i). The diagnosis is challenging due to the rarity, nonspecific symptoms, and absence of the alarmingly high blood glucose levels, and thus, it could be initially missed resulting in delayed treatment. This is particularly important for sedated patients, as the absence of typical clinical signs and symptoms can obscure the diagnosis. We present the case of a patient with type 2 diabetes mellitus on empagliflozin who developed EDKA while sedated after coronary artery bypass grafting (CABG) despite stopping the medication 24 hours prior to surgery. We also summarize the current literature on EDKA after CABG. Physicians must be aware and maintain a high index of suspicion for the illness, especially in patients with T2DM taking SGLT-2i and undergoing a major operation such as CABG. Emergent treatment and multidisciplinary follow-up are needed to improve patient outcomes and mitigate complications. Physicians should also consider identifying the optimal time to discontinue SGLT-2i before major surgeries and possible ketone studies in such patients, especially those sedated following the surgery.
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Seki H, Kuratani N, Shiga T, Iwasaki Y, Karita K, Yasuda K, Yorozu T. Multicentre prospective observational study of sodium-glucose cotransporter-2 inhibitor-associated postoperative ketoacidosis: the SAPKA study protocol. BMJ Open 2021; 11:e049592. [PMID: 34815277 PMCID: PMC8611445 DOI: 10.1136/bmjopen-2021-049592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new class of antihyperglycaemic agents that promote urinary glucose excretion in the renal proximal tubule and have cardio-protective and renal-protective properties. However, there are several safety concerns related to increased risks of hypoglycaemic, urinary tract infections and ketoacidosis. Ketoacidosis is a potentially fatal complication that often presents as euglycaemic ketoacidosis during SGLT2 inhibitor treatment. Furthermore, invasive treatment and related surgical stress may increase the risk of ketogenesis. Therefore, this study aims to clarify the incidence of SGLT2 inhibitor-associated postoperative ketoacidosis (SAPKA) among patients who are receiving SGLT2 inhibitors and undergoing surgery under general anaesthesia. METHODS AND ANALYSIS This multicentre, prospective, observational study will recruit 750 adult Japanese patients with diabetes who are receiving SGLT2 inhibitors and undergoing surgery under general anaesthesia. Urine samples will be collected on postoperative days 0, 1, 2 and 3. Blood gas analysis will be performed when urine ketone positivity is detected. The incidence of postoperative ketoacidosis will be identified based on urine ketone positivity and a blood pH of ≤7.3. The study will also collect data to identify risk factors for SAPKA. ETHICS AND DISSEMINATION The study protocol has been approved by the ethics committee of Kyorin University (approval number: 785, 26 October 2020) and local ethical approval will be required at each participating centre. Study findings will be submitted to peer-reviewed journals and abstracts will be submitted to relevant national and international meetings. TRIAL REGISTRATION NUMBER UMIN000042795.
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Affiliation(s)
| | | | - Toshiya Shiga
- Anesthesiology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
| | - Yudai Iwasaki
- Anesthesiology and Perioperative Medicine, Tohoku University, Sendai, Japan
| | - Kanae Karita
- Hygiene and Public Health, Kyorin University, Mitaka, Japan
| | - Kazuki Yasuda
- Diabetes, Endocrinology and Metabolism, Kyorin University, Mitaka, Japan
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Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021; 25:958-959. [PMID: 34733046 PMCID: PMC8559749 DOI: 10.5005/jp-journals-10071-23929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown. How to cite this article: Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021;25(8):958–959.
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Affiliation(s)
- Sonali Vadi
- Department of Intensive Care Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Vidhyadhar Lad
- Department of Cardiovascular Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, Maharashtra, India
| | - Dheeraj Kapoor
- Department of Endocrinology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Center, Mumbai, Maharashtra, India
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58
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Иванникова ЕВ, Алташина МВ, Трошина ЕА. [The ketogenic diet: history, mechanism of action, indications and contraindications]. PROBLEMY ENDOKRINOLOGII 2021; 68:49-72. [PMID: 35262297 PMCID: PMC9761873 DOI: 10.14341/probl12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 01/09/2023]
Abstract
Low-carb diets have been successfully used to alleviate a number of severe neurological diseases for about 100 years. The publication of the results of new studies suggesting that this type of diet may play a therapeutic role in other pathologies such as diabetes, obesity, polycystic ovary syndrome, and oncology is of particular interest for both doctors and the public. However, the long-term safety of using a low-carb or ketogenic diet, as well as its impact, primarily on the risks of developing cardiovascular diseases, remains poorly studied. This article presents the results of observation of patients against the background of a low-carbohydrate diet, both in the short-term perspective as well as provides an assessment of its long-term consequences.
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Affiliation(s)
| | - М. В. Алташина
- Национальный медицинский исследовательский центр
эндокринологии
| | - Е. А. Трошина
- Национальный медицинский исследовательский центр
эндокринологии
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59
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Menghoum N, Oriot P, Hermans MP. Clinical and biochemical characteristics and analysis of risk factors for euglycaemic diabetic ketoacidosis in type 2 diabetic individuals treated with SGLT2 inhibitors: A review of 72 cases over a 4.5-year period. Diabetes Metab Syndr 2021; 15:102275. [PMID: 34562870 DOI: 10.1016/j.dsx.2021.102275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS To study euglycemic diabetic ketoacidosis (euDKA) outcomes associated with sodium-glucose co-transporter 2 inhibitors (SGLT2is) METHODS: Review of 72 euDKA cases in T2DM between September 2015 and January 2020 (PUBMED). RESULTS euDKA could occur at any time during SGLT2is treatment, with nausea, abdominal pain and vomiting as main symptoms. Hyperglycemia did not correlate with pH and β-hydroxybutyrates. Low pH and high β-hydroxybutyrates were significantly associated with euDKA. In biguanides users, acidosis was unrelated to lactic acidosis. euDKA occurred during fasting, surgery, acute infection, insulin deprivation (endogenous or exogenous). CONCLUSIONS These data support avoidance of euDKA risk states in SGLT2i users.
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Affiliation(s)
- N Menghoum
- Department of Internal Medicine, Mouscron Hospital Center, Avenue de Fécamp 49, 7700, Mouscron, Belgium; Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, Catholic University of Louvain, 1200, Brussels, Belgium
| | - P Oriot
- Department of Internal Medicine, Mouscron Hospital Center, Avenue de Fécamp 49, 7700, Mouscron, Belgium; Department of Diabetology, Mouscron Hospital Centre, Avenue de Fécamp 49, 7700, Mouscron, Belgium.
| | - M P Hermans
- Endocrinology & Nutrition Unit, Cliniques Universitaires St-Luc, and Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, Catholic University of Louvain, Avenue Hippocrate 55, 1200, Brussels, Belgium
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60
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Pasqua MR, Tsoukas MA, Haidar A. Strategically Playing with Fire: SGLT Inhibitors as Possible Adjunct to Closed-Loop Insulin Therapy. J Diabetes Sci Technol 2021; 15:1232-1242. [PMID: 34558336 PMCID: PMC8655283 DOI: 10.1177/19322968211035411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As closed-loop insulin therapies emerge into clinical practice and evolve in medical research for type 1 diabetes (T1D) treatment, the limitations in these therapies become more evident. These gaps include unachieved target levels of glycated hemoglobin in some patients, postprandial hyperglycemia, the ongoing need for carbohydrate counting, and the lack of non-glycemic benefits (such as prevention of metabolic syndrome and complications). Multiple adjunct therapies have been examined to improve closed-loop systems, yet none have become a staple. Sodium-glucose-linked cotransporter inhibitors (SGLTi's) have been extensively researched in T1D, with average reductions in placebo-adjusted HbA1c by 0.39%, and total daily dose by approximately 10%. Unfortunately, many trials revealed an increased risk of diabetic ketoacidosis, as high as 5 times the relative risk compared to placebo. This narrative review discusses the proven benefits and risks of SGLTi in patients with T1D with routine therapy, what has been studied thus far in closed-loop therapy in combination with SGLTi, the potential benefits of SGLTi use to closed-loop systems, and what is required going forward to improve the benefit to risk ratio in these insulin systems.
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Affiliation(s)
- Melissa-Rosina Pasqua
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
- Melissa-Rosina Pasqua, MD, Mailing address:
McGill University Health Centre, 1001 boulevard de Décarie, Montreal, QC H4A
3J1, Canada.
| | - Michael A. Tsoukas
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering,
McGill University, Montreal, QC, Canada
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61
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Yeoh HL, Lee M, Pan WJ, Ong HY. Case of sodium-glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis. BMJ Case Rep 2021; 14:e235953. [PMID: 34404640 PMCID: PMC8375747 DOI: 10.1136/bcr-2020-235953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 12/12/2022] Open
Abstract
Following non-elective orthopaedic surgery, a 61-year-old man with poorly controlled type 2 diabetes mellitus on empagliflozin developed high anion gap metabolic acidosis in the high-dependency unit. Metabolic acidosis persisted despite intravenous sodium bicarbonate, contributing to tachycardia and a run of non-sustained ventricular tachycardia. He was euglycaemic throughout hospital admission. Investigations revealed elevated urine and capillary ketones, and a diagnosis of sodium-glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis was made. He was treated with an intravenous sliding scale insulin infusion and concurrent dextrose 5% with potassium chloride. Within 24 hours of treatment, his arterial pH, anion gap and serum bicarbonate levels normalised. After a further 12 hours, the intravenous insulin infusion was converted to a basal/bolus regimen of subcutaneous insulin, and he was transferred to the general ward. He was discharged well on subcutaneous insulin 6 days postoperatively.
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Affiliation(s)
- Huei Li Yeoh
- Pharmacy Department, Mount Elizabeth Novena Hospital, Singapore
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62
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Fookeerah P, Law H, Ali F, Chatten K, Kim C, Cheung NW. An audit of the effect of SGLT2 inhibitor cessation in a pre-admission clinic before and after Australian Diabetes Society guidelines. Intern Med J 2021; 51:980-983. [PMID: 34155765 DOI: 10.1111/imj.15366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
Perioperative ketoacidosis is an important adverse event related to the use of sodium glucose co-transporter 2 inhibitor (SGLT2i). We compared perioperative outcomes in patients on SGLT2i, before and after protocolised pre-operative cessation of the drug. There were no cases of clinically detected diabetic ketoacidosis in the 96 patients included in the study. Withdrawal of SGLT2i did not appear to alter significantly pre-operative glycaemia.
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Affiliation(s)
- Prishila Fookeerah
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Henry Law
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Farheen Ali
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Katherine Chatten
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Claire Kim
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ngai Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Wohlrab P, Kainz M, Schiferer A, Zapletal B, Tschernko E. Euglycemic Diabetic Ketoacidosis After Cardiac Surgery in a Patient Treated With Empagliflozin for Type 2 Diabetes Mellitus: A Case Report. J Cardiothorac Vasc Anesth 2021; 36:2066-2069. [PMID: 34465512 DOI: 10.1053/j.jvca.2021.07.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/16/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Peter Wohlrab
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Vienna, Austria.
| | - Matthias Kainz
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Vienna, Austria
| | - Arno Schiferer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Vienna, Austria
| | - Bernhard Zapletal
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Vienna, Austria
| | - Edda Tschernko
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiothoracic and Vascular Anesthesia, Medical University of Vienna, Vienna, Austria
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64
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Htet ZM, Karim M. Sodium-glucose co-transporter 2 inhibitors: game changers when handled with care? J R Soc Med 2021; 114:351-358. [PMID: 33945350 PMCID: PMC8415814 DOI: 10.1177/01410768211011109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 03/31/2021] [Indexed: 11/15/2022] Open
Abstract
Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.
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Affiliation(s)
- Zay M Htet
- Norfolk and Norwich University Hospital NHS Trust, Norwich NR4 7UY, UK
| | - Mahzuz Karim
- Norfolk and Norwich University Hospital NHS Trust, Norwich NR4 7UY, UK
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65
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Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Papanastasiou L, Glycofridi S, Gravvanis C, Skarakis N, Papadimitriou I, Kanti G, Kapsali C, Kounadi T. Diabetic ketoacidosis in patients treated with SGLT2 inhibitors: experience at a tertiary hospital. Hormones (Athens) 2021; 20:369-376. [PMID: 33151508 DOI: 10.1007/s42000-020-00256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Diabetic ketoacidosis (DKA) is a rare and life-threatening complication in patients with diabetes. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have rarely been associated with ketoacidosis. The aim of this retrospective study was to investigate DKA episodes occurring after SGLT2i treatment and to compare them to DKA episodes due to other causes. METHODS The medical records of the years 2018-2020 related to clinical and biochemical characteristics and to treatment of six patients with DKA due to SGLT2i were reviewed. They were compared to those of 12 patients with DKA due to other causes. RESULTS On admission, the most common symptom was abdominal pain. Glucose levels (median, min-max) were lower in patients with SGLT2i-induced DKA compared to those with DKA due to other causes (229 (150-481) vs. 458.5 (332-695) mg/dl, p = 0.007), whereas no statistical difference was observed in HbA1c and in the severity of DKA (pH, HCO3, CO2, and anion gap). The duration of insulin infusion (41 (33-124) vs. 21.50 (11-32) h, p < 0.001) and the time required until DKA resolution (39 (31-120) vs. 19 (9-28) h, p < 0.001) were higher in patients with SGLT2i-induced DKA than those with DKA due to other causes. In addition, there were increased fluid requirements (14 (8-22.75) vs. 5.5 (2-24) L, p = 0.013) and longer hospitalization time (11 (6-22) vs. 5.5 (2-14) days, p = 0.024) in patients with SGLT2i-induced DKA. No statistically significant differences were observed in total intravenous insulin and potassium administration until DKA resolution. CONCLUSIONS Patients with SGLT2i-induced DKA had lower serum glucose levels on admission and required increased fluid administration and longer time to recover from acidosis compared to patients with DKA from other causes.
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Affiliation(s)
- Labrini Papanastasiou
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece.
| | - Spyridoula Glycofridi
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Christos Gravvanis
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Nikitas Skarakis
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Irene Papadimitriou
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Georgia Kanti
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Chara Kapsali
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
| | - Theodora Kounadi
- Unit of Endocrinology and Diabetes Center, Athens General Hospital "G. Gennimatas", 154 Mesogion Avenue, 115 27, Athens, Greece
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Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes 2021; 12:514-523. [PMID: 33995841 PMCID: PMC8107974 DOI: 10.4239/wjd.v12.i5.514] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/01/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Sandeep Chaudhary
- Department of Endocrinology, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | | | - Aanchal Singh
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
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Lu H, Lu H, Kosinski C, Wojtusciszyn A, Zanchi A, Carron PN, Müller M, Meyer P, Martin J, Muller O, Hullin R. SGLT2 Inhibitors, What the Emergency Physician Needs to Know: A Narrative Review. J Clin Med 2021; 10:jcm10092036. [PMID: 34068655 PMCID: PMC8126052 DOI: 10.3390/jcm10092036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 01/10/2023] Open
Abstract
Canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin belong to a class of antidiabetic treatments referred to as sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors, or SGLT2is). SGLT2is are currently indicated in North America and in Europe in type 2 diabetes mellitus, especially in patients with cardiovascular (CV) disease, high CV risk, heart failure, or renal disease. In Europe, dapagliflozin is also approved as an adjunct to insulin in patients with type 1 diabetes mellitus. New data provide evidence for benefits in heart failure with reduced ejection fraction and chronic kidney disease, including in patients without diabetes. The use of SGLT2is is expected to increase, suggesting that a growing number of patients will present to the emergency departments with these drugs. Most common adverse events are easily treatable, including mild genitourinary infections and conditions related to volume depletion. However, attention must be paid to some potentially serious adverse events, such as hypoglycemia (when combined with insulin or insulin secretagogues), lower limb ischemia, and diabetic ketoacidosis. We provide an up-to-date practical guide highlighting important elements on the adverse effects of SGLT2is and their handling in some frequently encountered clinical situations such as acute heart failure and decompensated diabetes.
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Affiliation(s)
- Henri Lu
- Service of Cardiology, Cardiovascular Department, Lausanne University Hospital, 1011 Lausanne, Switzerland; (O.M.); (R.H.)
- Correspondence: ; Tel.: +41-79-556-03-89
| | - Hortense Lu
- Emergency Department, Saint-Joseph Hospital, 75014 Paris, France;
| | - Christophe Kosinski
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland; (C.K.); (A.W.); (A.Z.)
| | - Anne Wojtusciszyn
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland; (C.K.); (A.W.); (A.Z.)
| | - Anne Zanchi
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland; (C.K.); (A.W.); (A.Z.)
| | | | - Martin Müller
- Emergency Department, Bern University Hospital, 3010 Bern, Switzerland;
| | - Philippe Meyer
- Cardiology Service, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Jehan Martin
- Emergency Department, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Olivier Muller
- Service of Cardiology, Cardiovascular Department, Lausanne University Hospital, 1011 Lausanne, Switzerland; (O.M.); (R.H.)
| | - Roger Hullin
- Service of Cardiology, Cardiovascular Department, Lausanne University Hospital, 1011 Lausanne, Switzerland; (O.M.); (R.H.)
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Garla VV, Butler J, Lien LF. SGLT-2 Inhibitors in Heart Failure: Guide for Prescribing and Future Perspectives. Curr Cardiol Rep 2021; 23:59. [PMID: 33961133 DOI: 10.1007/s11886-021-01486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Heart failure is responsible for a significant part of diabetes-associated cardiovascular mortality and morbidity. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are novel agents approved for the treatment of diabetes mellitus; in recent clinical trials, these agents have shown a significant reduction in cardiovascular death and hospitalization secondary to heart failure. RECENT FINDINGS Clinical trials with specific heart failure outcomes have shown the benefit of SGLT-2 inhibitors in reducing the mortality and morbidity associated with heart failure. The guidelines for the management of diabetes mellitus recommend the preferential use of SGLT-2 inhibitors in patients with a history of cardiovascular disease. SGLT-2 inhibitors are potential game changers in the treatment of heart failure. Guidelines for prescription of these agents help assess risk-benefit analysis and personalize treatment for maximal benefit.
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Affiliation(s)
- Vishnu Vardhan Garla
- Endocrinology, Metabolism and Diabetes, Dept. of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA. .,Mississippi Center for Clinical and Translational Research, University of Mississippi Medical Center, Jackson, MS, USA. .,, Jackson, USA.
| | - Javed Butler
- Dept. of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lillian F Lien
- Endocrinology, Metabolism and Diabetes, Dept. of Internal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Kuchay MS, Mishra SK, Mehta Y. Empagliflozin induced euglycemic diabetic ketoacidosis in a patient undergoing coronary artery bypass graft despite discontinuation of the drug 48 hours prior to the surgery. Diabetes Metab Syndr 2021; 15:909-911. [PMID: 33915345 DOI: 10.1016/j.dsx.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Mohammad Shafi Kuchay
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, 122001, Haryana, India.
| | - Sunil Kumar Mishra
- Division of Endocrinology and Diabetes, Medanta The Medicity Hospital, Gurugram, 122001, Haryana, India
| | - Yatin Mehta
- Institute of Critical Care, Medanta The Medicity Hospital, Gurugram, 122001, Haryana, India
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Two cases of euglycemic diabetic ketoacidosis after bariatric surgery associated with sodium-glucose cotransporter-2 inhibitor use. Obes Surg 2021; 31:3848-3850. [PMID: 33895974 DOI: 10.1007/s11695-021-05391-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
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Smith A, Holtrop J, Sadoun M. Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy. Cureus 2021; 13:e14297. [PMID: 33968511 PMCID: PMC8097746 DOI: 10.7759/cureus.14297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A 51-year-old woman with type 2 diabetes mellitus developed euglycemic diabetic ketoacidosis (euDKA) in the post-operative setting after robotic-assisted sleeve gastrectomy. She developed tachycardia on post-operative day (POD) 1 before developing altered mental status and tachypnea on POD 2. The diagnosis was ultimately made by discovering ketonuria in the setting of anion gap metabolic acidosis despite repeatedly normal blood glucose levels. Pre-operatively, her blood glucose levels were managed with sodium-glucose co-transporter-2 (SGLT-2) inhibitor-containing combination pill, Invokamet®, as well as basal-bolus insulin regimen consisting of aspart (NovoLog®) and glargine-lixisenatide (Soliqua®). SLGT-2 inhibitors have been associated with an increased risk of euDKA, particularly in the context of severe bodily stressors such as surgery. EuDKA is a difficult diagnosis to make because of the lack of characteristic severe hyperglycemia that is typical of DKA. Clinicians should be mindful of euDKA in the post-operative setting of diabetic patients, particularly for those on SGLT-2 inhibitors.
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Affiliation(s)
- Alexander Smith
- Department of Endocrinology, Wayne State University School of Medicine, Detroit, USA
| | - John Holtrop
- Department of Surgery, Ascension St. John Hospital, Detroit, USA
| | - Moutamn Sadoun
- Department of Surgery, Ascension St. John Hospital, Detroit, USA
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Somagutta MR, Agadi K, Hange N, Jain MS, Batti E, Emuze BO, Amos-Arowoshegbe EO, Popescu S, Hanan S, Kumar VR, Pormento K. Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers. Cureus 2021; 13:e13665. [PMID: 33824816 PMCID: PMC8012260 DOI: 10.7759/cureus.13665] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 12/13/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is an acute and significant life-threatening complication of diabetes. The association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) with euglycemic diabetic ketoacidosis (EDKA) has been well reported. This literature review was conducted to understand the mechanism of EDKA and identify the potential risk factors and precipitants for patients taking SGLT2i. After reviewing the published literature between 2010 and 2020, 32 articles are included in the final review. The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.
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Affiliation(s)
- Manoj R Somagutta
- Department of Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Department of Medicine, Avalon University School of Medicine, Willemstad, CUW
| | | | - Namrata Hange
- Public Health, Woodlands Health Campus, Singapore, SGP
| | - Molly S Jain
- Department of Medicine, Saint James School of Medicine, Park Ridge, USA
| | - Erkan Batti
- Department of Medicine, Washington University Health and Science, San Pedro, BLZ
| | - Bernard O Emuze
- Emergency Medicine, Saint James School of Medicine, Fort Worth, USA
| | | | - Sorin Popescu
- Department of Medicine, Saint James School of Medicine, Park Ridge, USA
| | - Saad Hanan
- Department of Medicine, Saint James School of Medicine, Park Ridge, USA
| | | | - Kezia Pormento
- Department of Medicine, Ateneo de Manila School of Medicine and Public Health, Quezon City, PHL
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Pontes JPJ, de Melo CS, Arantes FBB, de Souza Ramos JTG, Módolo NSP, Navarro E Lima LH. Perioperative euglycemic diabetic ketoacidosis following use of SGLT-2 inhibitors after cardiac surgery. J Clin Anesth 2021; 71:110201. [PMID: 33647525 DOI: 10.1016/j.jclinane.2021.110201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/23/2022]
Affiliation(s)
- João Paulo Jordão Pontes
- Department of Anesthesiology, Complexo Hospitalar Santa Genoveva de Uberlândia, Minas Gerais, Brazil.
| | - Caroline Souto de Melo
- Department of Anesthesiology, Complexo Hospitalar Santa Genoveva de Uberlândia, Minas Gerais, Brazil
| | | | | | | | - Laís Helena Navarro E Lima
- Department of Anesthesiology, Sao Paulo State University, UNESP, Botucatu, Brazil; Department of Anesthesia and Perioperative Care, Queens University, Kingston, Canada
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Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med 2021; 44:157-160. [PMID: 33626481 DOI: 10.1016/j.ajem.2021.02.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States of America
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America
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Vadasz B, Arazi M, Shukha Y, Koren O, Taher R. Sodium-glucose cotransporter-2-induced euglycemic diabetic ketoacidosis unmasks latent autoimmune diabetes in a patient misdiagnosed with type 2 diabetes mellitus: a case report. J Med Case Rep 2021; 15:62. [PMID: 33581735 PMCID: PMC7882073 DOI: 10.1186/s13256-020-02607-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/30/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis is an uncommon but life-threatening complication associated with the use of sodium-glucose cotransporter 2 inhibitors that causes lower than expected blood glucose levels typically seen in diabetic ketoacidosis. CASE PRESENTATION We present a case of 64-year-old Caucasian male patient previously diagnosed with type 2 diabetes treated with a sodium-glucose cotransporter 2 inhibitor who developed severe ketoacidosis. Serum glucose levels on initial presentation were slightly above normal baseline level. The patient was revealed to have latent autoimmune diabetes in adults. CONCLUSION This case highlights the importance of prescribing sodium-glucose cotransporter 2 inhibitors to the correct patient population and the significance of accurately differentiating between various types of diabetes.
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Affiliation(s)
- Brian Vadasz
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mattan Arazi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yousef Shukha
- Internal Medicine Department E, Rambam HealthCare Campus, Ein IbrahimUmm alfahm, POD 4147, 300100 Haifa, Israel
| | - Ofir Koren
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Heart Institute, Emek Medical Center, Afula, Israel
| | - Riad Taher
- Internal Medicine Department E, Rambam HealthCare Campus, Ein IbrahimUmm alfahm, POD 4147, 300100 Haifa, Israel
- Department of Endocrinology, Rambam HealthCare Campus, Haifa, Israel
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77
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Puls HA, Haas NL, Franklin BJ, Theyyunni N, Harvey CE. Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series. Am J Emerg Med 2021; 44:11-13. [PMID: 33571749 DOI: 10.1016/j.ajem.2021.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Euglycemic diabetic ketoacidosis (EuDKA) associated with Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use has been described but remains poorly understood. Data on Emergency Department (ED) presentation, resource utilization, and safety outcomes for these patients are lacking. We report a case series of patients diagnosed with EuDKA in the ED. METHODS An electronic medical record search identified adult patients presenting to a large tertiary ED with EuDKA. They were screened for concurrent use of SGLT2i. Clinical presentation, resource utilization, safety, and disposition data were collected and described. RESULTS Five patients were included for analysis. Median age [range] was 57 [43-73] years. Presenting symptoms included nausea, vomiting, fatigue, and altered mental status. Initial results included: serum glucose 191 mg/dL [176-215], venous pH 7.01 [6.95-7.30], serum HCO3 8 mEq/L [6-13], anion gap 27 [26-31], serum beta-hydroxybutyrate 9.9 mmol/L [9.2-12.3], and urine ketones 150 [150-150]. Patients remained on an insulin infusion for 18.77 h [11.25-56.48]. There were zero episodes of hypoglycemia and one episode of hypokalemia while on insulin infusion. Time to resolution of metabolic acidosis was 23.82 h [15.45-24.77]. DISCUSSION We report a case series of ED patients with EuDKA associated with SGLT2i use, and describe presentation characteristics, resource utilization, and safety outcomes. Emergency physicians should be aware of the association between SGLT2i use and EuDKA. An appropriate work-up should be pursued for patients taking an SGLT2i who present with symptoms suggestive of DKA, including nausea, vomiting, malaise, and altered mental status, or are noted to have an unexplained elevated anion gap metabolic acidosis.
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Affiliation(s)
- Henrique A Puls
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Nathan L Haas
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | | | - Nik Theyyunni
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Carrie E Harvey
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
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Muneer M, Akbar I. Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:85-114. [PMID: 32488607 DOI: 10.1007/5584_2020_545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.
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Affiliation(s)
| | - Ijaz Akbar
- Shukat Khanam Cancer Hospital and Research Centre, Lahore, Pakistan
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Underwood L, Semchuk W, Albers L. A stepwise approach for pharmacists: Cardiovascular risk reduction with novel antihyperglycemic agents in patients with type 2 diabetes and atherosclerotic cardiovascular disease. Can Pharm J (Ott) 2021; 154:30-35. [PMID: 33598057 PMCID: PMC7863279 DOI: 10.1177/1715163520976149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Logan Underwood
- Department of Pharmacy Services, Regina General Hospital, Regina, Saskatchewan
| | - William Semchuk
- Department of Pharmacy Services, Regina General Hospital, Regina, Saskatchewan
| | - Lori Albers
- Department of Pharmacy Services, Regina General Hospital, Regina, Saskatchewan
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Dorcely B, Nitis J, Schwartzbard A, Newman JD, Goldberg IJ, Sum M. A Case Report: Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain in a Patient on a Low Carbohydrate Diet. Curr Diabetes Rev 2021; 17:243-246. [PMID: 32178617 PMCID: PMC8020366 DOI: 10.2174/1573399816666200316112709] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter-2 [SGLT2] inhibitors reduce cardiovascular events and mortality in patients with diabetes, particularly patients with established cardiovascular disease. Euglycemic diabetic ketoacidosis [euDKA], a complication of SGLT2 therapy, can be exacerbated by a low carbohydrate diet. CASE REPORT A 61-year-old man with a history of type 2 diabetes, taking an SGLT2 inhibitor empagliflozin 10 mg orally daily, presented to the emergency room with a 2-day history of nausea and chest pain. A week prior to presentation, he had started a ketogenic diet. He was initially admitted with a diagnosis of acute coronary syndrome. On initial assessment in the emergency room, his cardiac enzymes were normal and there were no ischemic changes in his ECG. As there was concern for unstable angina, he underwent cardiac catheterization, which showed a known total occlusion with collaterals and arteries with a non-obstructive disease without any evidence of acute plaque rupture. His baseline laboratory assessments revealed an elevated anion gap of 17, increased urinary and plasma ketones, and metabolic acidosis. His plasma glucose level was 84 mg/dL. The diagnosis of euDKA was made, and treatment with intravenous fluids and insulin was initiated. His chest pain and nausea subsequently resolved. CONCLUSION We present a case of euDKA triggered by a ketogenic diet while on SGLT2 inhibitor therapy presenting as chest pain. The recognition of euDKA is important in the context of increased SGLT2 use for the management of cardiovascular risk for patients with diabetes.
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Affiliation(s)
- Brenda Dorcely
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
- Address correspondence to this author at the Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA; Tel: 212-263-8077l; Fax: 212-481-1355;
| | - Juliana Nitis
- Vagelos College of Physicians and Surgeons-Columbia University, New York, NY 10032, USA
| | - Arthur Schwartzbard
- Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, 10016, USA
| | - Jonathan D. Newman
- Center for Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, 10016, USA
| | - Ira J. Goldberg
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
| | - Melissa Sum
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, NY 10016, USA
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Brinkmann C. Interaction Between Non-Insulin Glucose-Lowering Medication and Exercise in Type 2 Diabetes Mellitus - New Findings on SGLT2 Inhibitors. Front Endocrinol (Lausanne) 2021; 12:694099. [PMID: 34335470 PMCID: PMC8320760 DOI: 10.3389/fendo.2021.694099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christian Brinkmann
- Institute of Cardiovascular Research and Sport Medicine, Department of Preventive and Rehabilitative Sport Medicine, German Sport University Cologne, Cologne, Germany
- IST University of Applied Sciences, Düsseldorf, Germany
- *Correspondence: Christian Brinkmann,
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Osafehinti DA, Okoli OJ, Karam JG. A Case of SGLT2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis Following Coronary Artery Bypass Surgery. AACE Clin Case Rep 2020; 7:20-22. [PMID: 33851014 PMCID: PMC7924150 DOI: 10.1016/j.aace.2020.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel group of oral hypoglycemic agents with multiple proven beneficial effects. However, their use has been associated with euglycemic diabetic ketoacidosis (DKA), typically triggered by risk factors such as acute illness, surgery, and decreased calorie intake. Therefore, it is recommended that patients discontinue SGLT2 inhibitors at least 24 hours before surgery to minimize this risk. We report a case of a postoperative euglycemic DKA in a patient who had discontinued SGLT2 inhibitor therapy 48 hours prior to surgery. Methods We describe the clinical course of a patient with type 2 diabetes mellitus on empagliflozin therapy who was referred for coronary artery bypass graft surgery. Results A 60-year-old man with type 2 diabetes mellitus developed euglycemic DKA a few hours after coronary artery bypass graft surgery. Laboratory results showed acute postoperative elevated anion gap metabolic acidosis with normal glucose and elevated blood ketone levels. It was later revealed that the patient was treated as an outpatient with empagliflozin; the last dose was taken 48 hours prior to his procedure. Conclusion Euglycemic DKA can occur postoperatively in patients with a history of SGLT2 inhibitor use, even 48 hours after the discontinuation of therapy. This case highlights the need to revisit the recommended time to discontinue these agents, specifically prior to major surgery, because their pharmacokinetic effects may persist after 24 hours of discontinuation, putting patients at risk for postoperative euglycemic DKA.
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Affiliation(s)
| | - Ogochukwu J Okoli
- Department of Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Jocelyne G Karam
- Division of Endocrinology, Department of Medicine, Maimonides Medical Center, Brooklyn, New York
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83
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Vitale RJ, Valtis YK, McDonnell ME, Palermo NE, Fisher NDL. Euglycemic Diabetic Ketoacidosis With COVID-19 Infection in Patients With Type 2 Diabetes Taking SGLT2 Inhibitors. AACE Clin Case Rep 2020; 7:10-13. [PMID: 33521255 PMCID: PMC7833657 DOI: 10.1016/j.aace.2020.11.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective Diabetes mellitus is associated with poor outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Diabetic ketoacidosis (DKA) has also been reported to occur with this virus. A cluster of cases of euglycemic DKA (euDKA) was identified in patients with type 2 diabetes mellitus using sodium-glucose cotransporter-2 inhibitors (SGLT2is) who developed SARS-CoV-2 infection. Methods The cases were identified by the authors while providing clinical care, and details were collected. Results Five cases of euDKA, presenting with glucose levels <300 mg/dL, were identified over the course of 2 months by the endocrinology consult service. All patients had a history of type 2 diabetes mellitus with no known history of DKA. All were taking SGLT2is. Oral antihyperglycemic medications were stopped for all patients on admission. All received intravenous insulin infusion to treat DKA before being transitioned to a subcutaneous insulin regimen. SGLT2i use was discontinued for all patients who were discharged. Conclusion EuDKA has been seen in the setting of acute illness in patients using SGLT2is, but this cluster of cases suggests that there is a specific association with SARS-CoV-2 infection. In addition to the known risk of euDKA with SGLT2i use, coronavirus disease 2019-specific mechanisms may include a direct toxic effect of the virus on the pancreatic islets, an accelerated inflammatory response promoting ketosis, and the diuretic effect of SGLT2i in conjunction with anorexia and vomiting. It is crucial to counsel patients to stop SGLT2is when sick, especially if SARS-CoV-2 infection is suspected.
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Affiliation(s)
- Rebecca J Vitale
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yannis K Valtis
- Department of Medicine, Brigham and Women's Hospital, Medical Residency Office, Boston, Massachusetts
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Naomi D L Fisher
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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84
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Musso G, Sircana A, Saba F, Cassader M, Gambino R. Assessing the risk of ketoacidosis due to sodium-glucose cotransporter (SGLT)-2 inhibitors in patients with type 1 diabetes: A meta-analysis and meta-regression. PLoS Med 2020; 17:e1003461. [PMID: 33373368 PMCID: PMC7771708 DOI: 10.1371/journal.pmed.1003461] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) showed benefits in type 1 diabetes mellitus (T1DM), but the risk of diabetic ketoacidosis (DKA) limits their use. Ability to predict DKA risk and therapeutic responses would enable appropriate patient selection for SGLT2i. We conducted a meta-analysis and meta-regression of randomized controlled trials (RCTs) evaluating SGLT2i in T1DM to assess moderators of the relative risk (RR) of DKA, of glycemic (HbA1c, fasting plasma glucose, continuous glucose monitoring parameters, insulin dose, and insulin sensitivity indices) and non-glycemic (body mass index (BMI), systolic BP, renal function, albuminuria, and diabetic eye disorders) efficacy, and of other safety outcomes (including hypoglycemia, infections, major adverse cardiovascular events, and death). METHODS AND FINDINGS We searched MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials, and other electronic sources through August 30, 2020, for RCTs comparing SGLT2i with active comparators or placebo in adult patients with T1DM. Reviewers extracted data for relevant outcomes, performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. The strength of evidence was summarized with the GRADE approach. Among 9,914 records identified, 18 placebo-controlled RCTs (7,396 participants, 50% males, mean age 42 y (range 23 to 55 y), 5 different SGLT2i evaluated), were included. Main outcome measures were effect sizes and moderators of glycemic and non-glycemic efficacy and of safety outcomes. In a multivariable meta-regression model, baseline BMI (β = 0.439 [95% CI: 0.211, 0.666], p < 0.001) and estimated glucose disposal rate (eGDR) (β = -0.766 [-1.276, -0.256], p = 0.001) were associated with the RR of DKA (RR: 2.81; 95% CI:1.97, 4.01; p < 0.001, R2 = 61%). A model including also treatment-related parameters (insulin dose change-to-baseline insulin sensitivity ratio and volume depletion) explained 86% of variance across studies in the risk of DKA (R2 = 86%). The association of DKA with a BMI >27 kg/m2 and with an eGDR <8.3 mg/kg/min was confirmed also in subgroup analyses. Among efficacy outcomes, the novel findings were a reduction in albuminuria (WMD: -9.91, 95% CI: -16.26, -3.55 mg/g, p = 0.002), and in RR of diabetic eye disorders (RR: 0.27[0.11, 0.67], p = 0.005) associated with SGLT2i. A SGLT2i dose-response gradient was consistently observed for main efficacy outcomes, but not for adverse events (AEs). Overall, predictors of DKA and of other AEs differed substantially from those of glycemic and non-glycemic efficacy. A limitation of our analysis was the relatively short (≤52 weeks) duration of included RCTs. The potential relevance for clinical practice needs also to be confirmed by real-world prospective studies. CONCLUSIONS In T1DM, the risk of DKA and main therapeutic responses to SGLT2i are modified by baseline BMI and insulin resistance, by total insulin dose reduction-to-baseline insulin sensitivity ratio, and by volume depletion, which may enable the targeted use of these drugs in patients with the greatest benefit and the lowest risk of DKA.
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Affiliation(s)
| | - Antonio Sircana
- Department of Cardiology, Azienda Ospedaliero Universitaria, Sassari, Italy
| | - Francesca Saba
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maurizio Cassader
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberto Gambino
- Laboratory of Diabetes and Metabolic disorders, Department of Medical Sciences, University of Turin, Turin, Italy
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Predisposing factors for the development of diabetic ketoacidosis with lower than anticipated glucose levels in type 2 diabetes patients on SGLT2-inhibitors: a review. Eur J Clin Pharmacol 2020; 77:651-657. [PMID: 33244632 DOI: 10.1007/s00228-020-03051-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/20/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE SGLT2-inhibitors (SGLT-2i) have been linked to the risk of potential life-threatening diabetic ketoacidosis (DKA). The U.S. Food and Drug Administration and the European Medicines Agency issued warnings in 2015 and 2016 respectively on the predisposing factors to the development of DKA in individuals on an SGLT2i. New predisposing factors to DKA are still being discovered with the use of SGLT-2i. The list by FDA and EMA is yet to be updated. This article aims to provide a holistic list that includes the newer factors that have been implicated in the development of DKA. The overall aim is to guide physicians in prescribing this class of drugs for type 2 diabetes mellitus (T2D). METHOD A search was done using PUBMED, Google Scholar, and Directory of Open Access Journals with the following words: SGLT-2 Inhibitors AND Ketoacidosis were entered. We included articles from 2000 to 2020, those in English, those involving any of the approved SGLT2i medications in T2D patients, and studies that focused on DKA linked to SGLT-2i. These articles were reviewed, and relevant data extracted and compiled. RESULTS AND CONCLUSION The review has revealed that predisposing factors include (excess) alcohol consumption, female gender, starvation due to illness or fasting, withholding the use of SGLT2i for less than 48 h peri-operatively, and the existence of a variations in the expression of SGLT2 receptors. Patients should be advised on "sick day rules," and if a patient becomes unwell while on an SGLT2i, they should be advised to withhold the medication for the duration of the intercurrent illness.
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SGLT-2 Inhibitors-a Culprit of Diabetic Ketoacidosis Postbariatric Surgery. Case Rep Crit Care 2020; 2020:8817829. [PMID: 33204542 PMCID: PMC7661140 DOI: 10.1155/2020/8817829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/29/2020] [Indexed: 01/14/2023] Open
Abstract
Sodium-glucose cotransporter-2 SGLT2 inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. They have grown increasingly popular over recent years, as they have been shown to have some protective effects on the heart and kidneys, both organ systems that diabetes mellitus has shown to have deleterious effect on over time. Despite their growing popularity, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a case series of three cases of euglycemic DKA postbariatric surgery in patients with an underlying history of type 2 diabetes mellitus, who were being treated with SGLT2 inhibitors prior to the surgery. All three patients reported to the emergency room with signs, symptoms, and clinical findings of euglycemic DKA. The AACE recommends SGLT2 inhibitors to be discontinued at least 24 hours prior to surgery and resumed when a patient resumes a normal diet. Our patients presented with euglycemic DKA after bariatric surgery, and we recommend more research should be done targeted at the prolonged postoperative course of patients on SGLT-2 inhibitors and into creating specific guidelines for their use after bariatric surgery.
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Cosentino F, Ceriello A, Baeres FMM, Fioretto P, Garber A, Stough WG, George JT, Grant PJ, Khunti K, Langkilde AM, Plutzky J, Rydén L, Scheen A, Standl E, Tuomilehto J, Zannad F. Addressing cardiovascular risk in type 2 diabetes mellitus: a report from the European Society of Cardiology Cardiovascular Roundtable. Eur Heart J 2020; 40:2907-2919. [PMID: 30445605 DOI: 10.1093/eurheartj/ehy677] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/20/2018] [Accepted: 10/08/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Francesco Cosentino
- Cardiology Unit, Department of Medicine Solna, Karolinska Institute & Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Italy
| | | | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Alan Garber
- Baylor College of Medicine, Houston, Texas, USA
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Cary, North Carolina, USA
| | - Jyothis T George
- Boehringer Ingelheim International, Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Jorge Plutzky
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lars Rydén
- Department of Medicine, K2, Karolinska Institute, Stockholm, Sweden
| | - André Scheen
- Division of Diabetes, Nutrition, and Metabolic Disorders, Division of Clinical Pharmacology, CHU de Liège, University of Liège, Liège, Belgium
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Jaakko Tuomilehto
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
- Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques- 1433, and Inserm U1116, CHRU, Nancy, France
- Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT, Nancy, France
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88
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Affiliation(s)
- Giovanni Musso
- Emergency and Intensive Care Medicine, HUMANITAS Gradenigo Hospital; Laboratory of Diabetology and Metabolism, Department of Medical Sciences, Città della Salute, University of Turin, Italy
| | - Francesca Saba
- Laboratory of Diabetology and Metabolism, Department of Medical Sciences, University of Turin
| | - Maurizio Cassader
- Clinical Biochemistry, Laboratory of Diabetology and Metabolism, Department of Medical Sciences, University of Turin
| | - Roberto Gambino
- Clinical Biochemistry, Laboratory of Diabetology and Metabolism, Department of Medical Sciences, University of Turin
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Lindsay PJ, Gibson LE, Bittner EA, Berg S, Chang MG. Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced euglycemic diabetic ketoacidosis complicating the perioperative management of a patient with type 2 diabetes mellitus (T2DM) and Fournier's gangrene: A case report. Int J Surg Case Rep 2020; 77:463-466. [PMID: 33395826 PMCID: PMC7695895 DOI: 10.1016/j.ijscr.2020.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
This case highlights two serious side effects of empagliflozin occurring concurrently. Those being diabetic ketoacidosis and Fournier’s gangrene. Diabetic ketoacidosis is an important cause of perioperative high anion gap metabolic acidosis in the context of SGLT2 inhibitors and needs to be carefully managed. SGLT2 inhibitors should be held up to 48 h prior to surgery to minimize the risk of diabetic ketoacidosis perioperatively.
Introduction Sodium glucose cotransporter-2 inhibitors (SGLT2) are an increasingly administered class of medication used to lower blood glucose levels in patients with type 2 diabetes mellitus. Diabetic ketoacidosis (DKA) and Fournier’s gangrene are rare, but potentially catastrophic side effects of SGLT2 inhibitors. This manuscript reports a case of both DKA and Fournier’s gangrene in the context of SGLT2 inhibitor use. Presentation of case A 51-year-old morbidly obese man with hypertension and poorly controlled Type 2 Diabetes Mellitus presented to the emergency department with a clinical presentation consistent with Fournier’s gangrene. He was promptly taken to the operating room by the urology team where he had extensive debridement of the perineum and abdomen. Intra-operatively he was found to have DKA, which was managed appropriately. The acidosis and Fournier’s gangrene were deemed a likely side effect of SGLT2 inhibitor use. After a thirty-day hospital admission, the patient was discharged to a rehabilitation facility where he is progressing well. His SGLT2 inhibitor was discontinued upon admission to hospital. Discussion Perioperative providers should have a high index of suspicion for diabetic ketoacidosis (DKA) and Fournier’s gangrene in patients prescribed SGLT2 inhibitors. Prompt treatment of DKA through correction of underlying triggers, aggressive fluid resuscitation, insulin to close the anion gap, and appropriate potassium repletion is vital to optimize patient outcomes. Conclusion The use of SGLT2 inhibitors among surgical populations is increasing. This case highlights the importance of being aware of the mechanism and side effects of SGLT2 inhibitors, and the management of DKA.
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Affiliation(s)
- Patrick J Lindsay
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA.
| | - Lauren E Gibson
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Sheri Berg
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
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90
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Peters AL, McGuire DK, Danne T, Kushner JA, Rodbard HW, Dhatariya K, Sawhney S, Banks P, Jiang W, Davies MJ, Lapuerta P. Diabetic Ketoacidosis and Related Events With Sotagliflozin Added to Insulin in Adults With Type 1 Diabetes: A Pooled Analysis of the inTandem 1 and 2 Studies. Diabetes Care 2020; 43:2713-2720. [PMID: 32928957 PMCID: PMC7576419 DOI: 10.2337/dc20-0924] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/09/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors for diabetic ketoacidosis (DKA) and related adverse events (AEs) in adults with type 1 diabetes treated with sotagliflozin adjunctive to insulin. RESEARCH DESIGN AND METHODS Data from two identically designed, 52-week, randomized studies were pooled and analyzed for DKA, changes in β-hydroxybutyrate (BHB), and percentage of patients with BHB >0.6 and >1.5 mmol/L. The patients were administered placebo, sotagliflozin 200 mg, or sotagliflozin 400 mg once daily. RESULTS A total of 191 ketosis-related AEs were reported, and 98 underwent adjudication. Of these, 37 events (36 patients) were adjudicated as DKA, with an exposure-adjusted incidence rate of 0.2, 3.1, and 4.2 events per 100 patient-years for placebo, sotagliflozin 200 mg, and sotagliflozin 400 mg, respectively. No patient died of a DKA event. From a baseline BHB of ∼0.13 mmol/L, sotagliflozin treatment led to a small median increase over 52 weeks (≤0.05 mmol/L at all time points). Of sotagliflozin-treated patients, approximately 47% and 7% had ≥1 BHB measurement >0.6 mmol/L and >1.5 mmol/L, respectively (vs. 20% and 2%, respectively, of placebo-treated patients). Subsequent to the implementation of a risk mitigation plan, annualized DKA incidence was lower versus preimplementation in both the sotagliflozin 200 and 400 mg groups. CONCLUSIONS In patients with type 1 diabetes, confirmed DKA incidence increased when sotagliflozin was added to insulin compared with insulin alone. A lower incidence of DKA was observed following the implementation of an enhanced risk mitigation plan, suggesting that this risk can be managed with patient education.
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Affiliation(s)
- Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Thomas Danne
- Kinder Krakenhaus auf der Bult, Diabetes Zentrum für Kinder and Jugendliche, Hannover, Germany
| | | | - Helena W Rodbard
- Endocrine and Metabolic Consultants Research Center, Rockville, MD
| | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norwich, U.K
| | | | | | - Wenjun Jiang
- Lexicon Pharmaceuticals, Inc., The Woodlands, TX
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91
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COVID-19-associated euglycemic diabetic ketoacidosis in a patient with type 2 diabetes on SGLT2 inhibitor: a case report. Diabetol Int 2020; 12:313-316. [PMID: 33133998 PMCID: PMC7592186 DOI: 10.1007/s13340-020-00473-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/15/2020] [Indexed: 12/12/2022]
Abstract
Type 2 diabetes mellitus (DM) patients are at high risk for the development of severe COVID-19. Euglycemic diabetic ketoacidosis (eu-DKA) is a rare life-threatening complication associated with the use of SGLT2 inhibitor that may be unnoticed, particularly in a pandemic setting, due to the absence of significant hyperglycemia, delaying its treatment. In this report, we describe a case of a 56-year-old patient who presented an elevated anion gap metabolic acidosis during a SARS-CoV-2 infection and was diagnosed with SGLT2-associated euglycemic diabetic ketoacidosis. COVID-19 may increase patients’ insulin demand, present gastrointestinal symptoms, and increase the production of ketone bodies. This situation can be worsened in susceptible diabetic patients on SLGT2 inhibitors, due to the persistent glycosuria, which can cause volume depletion. Recently some authors recommended that insulin-deficient patients or those using SGLT2 inhibitors should monitor for ketosis using available home testing kits in case of infections and should discontinue the medication in case of COVID-19. Given the increased use of this drug class in the management of type 2 DM patients due to its reduction of cardiovascular risk, we set out to emphasize the importance for the medical community to consider the possibility of eu-DKA on SARS-CoV-2-infected patients using SLGT2 inhibitors, so physicians can provide these patients with appropriate therapy promptly.
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92
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Chatzopoulos G, Tziomalos K. An up-to-date evaluation of sotagliflozin for the treatment of type 1 diabetes. Expert Opin Pharmacother 2020; 21:1799-1803. [DOI: 10.1080/14656566.2020.1793961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Georgios Chatzopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Mechanick JI, Rosenson RS, Pinney SP, Mancini DM, Narula J, Fuster V. Coronavirus and Cardiometabolic Syndrome: JACC Focus Seminar. J Am Coll Cardiol 2020; 76:2024-2035. [PMID: 33092738 PMCID: PMC7571973 DOI: 10.1016/j.jacc.2020.07.069] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic exposes unexpected cardiovascular vulnerabilities and the need to improve cardiometabolic health. Four cardiometabolic drivers-abnormal adiposity, dysglycemia, dyslipidemia, and hypertension-are examined in the context of COVID-19. Specific recommendations are provided for lifestyle change, despite social distancing restrictions, and pharmacotherapy, particularly for those with diabetes. Inpatient recommendations emphasize diligent and exclusive use of insulin to avert hyperglycemia in the face of hypercytokinemia and potential islet cell injury. Continuation of statins is advised, but initiating statin therapy to treat COVID-19 is as yet unsubstantiated by the evidence. The central role of the renin-angiotensin system is discussed. Research, knowledge, and practice gaps are analyzed with the intent to motivate prompt action. An emerging model of COVID-related cardiometabolic syndrome encompassing events before, during the acute phase, and subsequently in the chronic phase is presented to guide preventive measures and improve overall cardiometabolic health so future viral pandemics confer less threat.
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Affiliation(s)
- Jeffrey I Mechanick
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Robert S Rosenson
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean P Pinney
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Donna M Mancini
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jagat Narula
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York
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Milder TY, Stocker SL, Day RO, Greenfield JR. Potential Safety Issues with Use of Sodium-Glucose Cotransporter 2 Inhibitors, Particularly in People with Type 2 Diabetes and Chronic Kidney Disease. Drug Saf 2020; 43:1211-1221. [PMID: 33095409 PMCID: PMC7582030 DOI: 10.1007/s40264-020-01010-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 12/31/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a major advance in the fields of diabetology, nephrology, and cardiology. The cardiovascular and renal benefits of SGLT2 inhibitors are likely largely independent of their glycaemic effects, and this understanding is central to the use of these agents in the high-risk population of people with type 2 diabetes and chronic kidney disease. There are a number of potential safety issues associated with the use of SGLT2 inhibitors. These include the rare but serious risks of diabetic ketoacidosis and necrotising fasciitis of the perineum. The data regarding a possibly increased risk of lower limb amputation and fracture with SGLT2 inhibitor therapy are conflicting. This article aims to explore the potential safety issues associated with the use of SGLT2 inhibitors, with a particular focus on the safety of these drugs in people with type 2 diabetes and chronic kidney disease. We discuss strategies that clinicians can implement to minimise the risk of adverse effects including diabetic ketoacidosis and volume depletion. Risk mitigation strategies with respect to SGLT2 inhibitor-associated diabetic ketoacidosis are of particular importance during the current coronavirus disease 2019 (COVID-19) pandemic.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, Australia.,St. Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, Australia. .,Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, Australia. .,St. Vincent's Clinical School, University of NSW, Sydney, Australia.
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95
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Abstract
Diabetes mellitus (DM) is an increasingly prevalent condition that has a significant impact on health systems worldwide, particularly in older people. It is estimated that 30% of people aged > 65 years fulfil the diagnostic criteria for DM, with 90% having type 2 DM (T2DM). Generally, specific guidelines for the treatment of T2DM in older people address in a very limited manner the use of more recent therapies, such as sodium-glucose co-transporter-2 inhibitors (SGLT2i), which have important benefits for older people, such as a low risk of hypoglycemia, reduction of cardiovascular and renal risk, and an insulin-independent mechanism, allowing its use in disease of any duration. The SGLT2i class is well-tolerated, though some caution is also suggested, including adjustment of concomitant therapies, such as insulin and antihypertensives, especially loop diuretics. This review discusses the pathophysiological characteristics of the older patient with T2DM and evaluates the main benefits of and cautions for the use of SGLT2i in this population.
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96
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Iqbal QZ, Mishiyev D, Zia Z, Ruggiero RA, Aftab G. Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature. Cureus 2020; 12:e10878. [PMID: 33178530 PMCID: PMC7652357 DOI: 10.7759/cureus.10878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. SGLT-2 Inhibitors function by inhibiting renal cotransporters, which reduces the reabsorption of glucose in the kidney, ultimately decreasing the concentration of glucose in the body. They have gained popularity in recent years due to their protective effects on the heart and kidneys - both organ systems that diabetes mellitus has shown to have a deleterious effect on. However, despite their growing fame, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is particularly dangerous as there is a chance that it can be missed by clinicians due to glucose levels generally being less than 200 mg/dL. There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a brief review of the literature regarding this important side effect of SGLT-2 inhibitors seen in patients after bariatric surgery.
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Affiliation(s)
| | | | - Zeeshan Zia
- Internal Medicine, Northwell Health, New York, USA
| | | | - Ghulam Aftab
- Pulmonary Medicine, Saint Peter's University Hospital, New Brunswick, USA
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97
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Yared KE, Mancini GJ. Euglycemic Diabetic Ketoacidosis Associated With Use of SGLT2 Inhibitor After Laparoscopic Roux-en-Y Gastric Bypass. Am Surg 2020; 87:1997-1999. [PMID: 32812784 DOI: 10.1177/0003134820940286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Katherine E Yared
- 21823 Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Gregory J Mancini
- 21823 Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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98
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Chen MB, Xu RJ, Zheng QH, Zheng XW, Wang H. Efficacy and safety of sotagliflozin adjuvant therapy for type 1 diabetes mellitus: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20875. [PMID: 32871972 PMCID: PMC7437859 DOI: 10.1097/md.0000000000020875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND To systematically evaluate the efficacy and safety of sotagliflozin (SOTA) adjuvant therapy for type 1 diabetes mellitus (T1DM). METHODS Through April 2019, the Web of Science, PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure databases were electronically searched to identify randomized controlled trials exploring SOTA adjuvant therapy for T1DM. Strict screening and quality evaluations of the obtained literature were performed independently by 2 researchers. Outcome indexes were extracted, and a meta-analysis of the data was performed using Revman 5.3 software. RESULTS A total of 7 randomized controlled trials were included. The meta-analysis results showed that compared with the patients in the placebo group, the patients in the SOTA group had a lower hemoglobin A1c (mean difference [MD] = -0.28, 95% confidence interval [CI] [-0.34, -0.22], P < .01), lower total daily insulin use (MD = -8.89, 95% CI [-11.64, -6.13], P < .01), faster weight loss (MD = -3.03, 95% CI [-3.79, -2.26], P < .01), better fasting blood glucose and 2-hour postprandial blood glucose control (MD = -0.75, 95% CI [-1.04, -0.45], P < .01; MD = -2.42, 95% CI [-3.17, -1.67], P < .01), and a higher rate of well-controlled glucose levels (relative risk = 1.75, 95% CI [1.55, 1.99], P < .01), while no significant difference in the incidence of severe hypoglycemic events was found between the SOTA and placebo groups (risk difference [RD] = -0.01, 95% CI [-0.02, 0.00], P = .13). The incidence of diabetic ketoacidosis was higher in the SOTA group than in the placebo group (RD = 0.03, 95% CI [0.02, 0.04], P < .01). The incidence of genital mycotic infection was higher in the SOTA group than in the placebo group (RD = 0.06, 95% CI [0.05, 0.08], P < .01). No significant difference in the incidence of urinary tract infections was detected between the SOTA group and the placebo group (RD = 0.00, 95% CI [-0.01, 0.01], P = 0.97). CONCLUSIONS SOTA is a potential drug for the treatment of T1DM and is effective for controlling blood sugar. The main adverse reactions to SOTA are genital mycotic infections and diabetic ketoacidosis. We must further assess the severity of diabetic ketoacidosis caused by SOTA.
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Affiliation(s)
| | | | | | | | - Hua Wang
- Department of ICU, Wujin People Hospital Affiliated with Jiangsu University, and the Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu, P. R. China
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99
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Sartori D, Aronson JK, Onakpoya IJ. Signals of adverse drug reactions communicated by pharmacovigilance stakeholders: protocol for a scoping review of the global literature. Syst Rev 2020; 9:180. [PMID: 32791982 PMCID: PMC7425142 DOI: 10.1186/s13643-020-01429-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Signals of adverse drug reactions (ADRs) form the basis of some regulatory risk-minimization actions in pharmacovigilance. Reviews of limited scope have highlighted that such signals are mostly supported by reports of ADRs or multiple types of evidence. The time that elapses between a report of a suspected ADR and the communication of a signal has not been systematically characterized. Neither has the features of reports of suspected ADRs that authors used to support putative causal relationships, although difficulties with establishing causal relationships between medicinal products and adverse events have been highlighted. The objectives of this study will be to describe the evidence underpinning signals in pharmacovigilance, the features of reports of ADRs supporting signals, and the time that it takes to communicate a signal. METHODS We shall retrieve records from PubMed, EMBASE, Web of Science, and PsycINFO (from inception onwards), without language/design restrictions, and apply backward citation screening. We shall hand-search the websites of 35 regulatory agencies/authorities, restricted publications from the Uppsala Monitoring Centre, and drug bulletins. Signals will be requested from the competent stakeholder, if absent from websites. We shall use VigiBase, the World Health Organization's Global Individual Case Safety Report database, to determine the dates on which ADRs were reported. We shall manage records using EndNote (v. 8.2); one reviewer will screen titles/abstracts and full texts, a second will cross-validate the findings, and a third will arbitrate disagreements. Data will be charted via the Systematic Reviews Data Repository, following the same procedures as for data retrieval. Evidence will be categorized according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Features of reports of ADRs will be coded. Tables will display frequencies of types of evidence and features of reports of ADRs. We shall use plots or pictograms (if appropriate) to represent the time from the first report of a suspected ADR to a signal. DISCUSSION We expect the findings from this review will allow a better understanding of global patterns of similarities or differences in terms of supporting evidence and timing of communications and identify relevant research questions for future systematic reviews. SYSTEMATIC REVIEW REGISTRATION: osf.io/a4xns.
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Affiliation(s)
- Daniele Sartori
- Uppsala Monitoring Centre, Bredgränd 7B, 753 20, Uppsala, Sweden.
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Igho J Onakpoya
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, United Kingdom
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100
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Beware Ketoacidosis with SGLT2 Inhibitors in Latent Autoimmune Diabetes of the Adult. Am J Med 2020; 133:e422-e424. [PMID: 31923401 DOI: 10.1016/j.amjmed.2019.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/11/2019] [Accepted: 12/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors are increasingly used for the treatment of type 2 diabetes, but have been associated with ketoacidosis. METHODS/RESULTS We report a case series of three patients with latent autoimmune diabetes of the adult who presented with ketoacidosis, including one case with normal blood glucose levels, in the context of SGLT2 inhibitor use. CONCLUSIONS Sodium-glucose co-transporter-2 inhibitors should be used with caution and close clinical monitoring in patients with latent autoimmune diabetes of the adult. A clinical risk score permits targeted autoantibody testing and should be undertaken prior to commencement of SGLT2 inhibitors or cessation of insulin.
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