Prolonged ketosis and glycosuria secondary to SGLT2 inhibitor therapy

Euglycemic Ketoacidosis in a Patient without Diabetes Taking Sodium-Glucose Cotransporter 2 Inhibitors for Heart Failure

BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors are used to improve the prognosis of patients with diabetes, heart failure, or chronic kidney disease. The use of SGLT2 inhibitors in patients without diabetes is expected to increase. Diabetic ketoacidosis is a severe complication of SGLT2 inhibitors in patients with diabetes. People without diabetes are thought to be less likely to develop ketoacidosis, and reports of SGLT2 inhibitor-induced ketoacidosis are uncommon in people without diabetes. CASE REPORT Herein, we describe a case of ketoacidosis in an 83-year-old Japanese woman without diabetes who was administered SGLT2 inhibitors for heart failure (ejection fraction: approximately 30%). Two weeks prior to admission, she had suffered a vertebral fracture and rib fracture due to a fall, which was followed by anorexia, but she continued to take SGLT2 inhibitors. On admission, blood test results revealed a blood glucose level of 124 mg/dL, hemoglobin A1C level of 5.9%, pH of 7.329, HCO₃⁻ concentration of 14.3 mmol/L, and a ß-hydroxybutyrate concentration of 5150 μmol/L, leading to a diagnosis of euglycemic ketoacidosis. The patient's C-peptide level was consistent with the blood glucose levels on admission, indicating that she had adequate insulin secretion. The patient was treated only with glucose administration without insulin and was discharged after discontinuation of the SGLT2 inhibitor. CONCLUSIONS This case illustrates that patients with or without diabetes may develop SGLT2 inhibitor-related ketoacidosis after several days of inadequate food intake; therefore, patients should be informed of this risk.

Prolonged Diabetic Ketoacidosis Associated With Sodium-Glucose Cotransporter-2 Inhibitors: A Review of Postmarketing Cases

OBJECTIVE

To describe reported cases of prolonged or relapsed ketoacidosis (KA) in adults with type 2 diabetes receiving treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors.

METHODS

We performed a search of the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System and medical literature, to identify our case series and to characterize cases of prolonged KA, relapsed KA, or persistent ketonemia, persistent ketonuria and/or persistent glucosuria in adults receiving SGLT2 inhibitors.

RESULTS

The FDA identified 29 unique cases of prolonged or relapsed KA, as well as related terms persistent ketonemia, persistent ketonuria, and persistent glucosuria, in patients receiving SGLT2 inhibitors through July 26, 2022. The patients ranged in age from 26 to 85 years. Treatment duration of KA ranged from 3 to 20 days. There were 7 cases of relapsed KA when insulin was reduced or transitioned to subcutaneous route. Arterial pH value was 7.0 or below in 4 patients, and the median pH was 7.1. Associated factors for prolonged or relapsed KA included surgery, decreased caloric intake, and ketogenic/carbohydrate restricted diet. A total of 62% of the patients were taking 3 or more glycemic control medications including the SGLT2 inhibitor. All patients with sufficient follow-up information recovered.

CONCLUSION

Although KA is a well-known risk associated with SGLT2 inhibitors, this case series demonstrated the potential for prolonged or recurrent KA events with serious outcomes. These cases informed updates to FDA's prescribing information to inform prescribers of this risk.

ERRATUM

[This corrects the article DOI: 10.1002/ccr3.5057.].