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Hussaini SA, Aziz A, Musa M, Alamin M, Danjuma M. Late-Onset Euglycemic Diabetic Ketoacidosis in a Patient With Massive Stroke Requiring Decompressive Craniectomy: A Case Report. Cureus 2021; 13:e18629. [PMID: 34765377 PMCID: PMC8575253 DOI: 10.7759/cureus.18629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 11/18/2022] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is a well-recognized adverse effect associated with the use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. Early recognition of this medical emergency and timely intervention can prevent the notorious consequences of this serious complication. However, this form of DKA can easily be masqueraded by normal serum glucose levels. This article describes a 49-year-old man diagnosed with type 2 diabetes mellitus (DM) on dapagliflozin who presented with a large right-sided middle cerebral artery (MCA) stroke complicated by euglycemic DKA, developed 72 hours after stopping the drug. This case is unique considering that dapagliflozin's half-life is only 12.9 hours, and the body completely eliminates it within 72 hours. But our patient developed DKA features after the elimination window. Hence, this case highlights the importance to consider euglycemic DKA in the presence of ketonemia and metabolic acidosis in a patient who is a chronic SGLT-2 inhibitor user even if the drug was discontinued several days before the patient's presentation.
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Affiliation(s)
| | - Afia Aziz
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | - Muzamil Musa
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
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2
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Comparative efficacy of empagliflozin versus placebo in the treatment of type 1 diabetes mellitus: a meta-analysis of randomized controlled trials. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2021. [DOI: 10.2478/cipms-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The objective of this meta-analysis study was to evaluate the comparative efficacy of empagliflozin (25 mg) with placebo in the treatment and management of type 1 diabetes mellitus. This study is a meta-analysis, so an ethical statement is not required. Different databases and individual journal websites like SCOPUS, Science direct, Cochrane review library etc. were used. The articles were evaluated based on the search and eligibility criteria. A total of five RCTs were incorporated in this meta-analysis. These studies contained a total of 1058 patients, including 526 patients with placebo (or control-treated patients), and 532 patients with empagliflozin (25 mg) treated combination. The mean follow-up time ranged from 7 days to 6 months. Overall, mean reduction in placebo was -0.50% and empa-treated was -0.85%, while the pooled WMD was 3.82 995% CI 1.20 – 5.88, p=0.0001). Regarding urinary glucose excretion, that the pooled WMD was 6.67 (95% CI 4.87-10.14, p=0.001) indicated a significant increase in empa-arm compared to placebo. No heterogeneity was found (I2 – 15.03%). This meta-analysis underlined the therapeutic benefit of empagliflozin as an adjunctive therapy for patients with type 1 diabetes.
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Abu-Zaid A, Altowairqi AK, Dissanayaka T, Oganesyan A, Bhagavathul AS, Alhabeeb H, Baradhwan A, Alomar S, Tom S. A systematic review and dose-response meta-analysis on the efficacy of dapagliflozin in patients with type 1 diabetes mellitus. Pharmacol Res 2021; 165:105456. [PMID: 33515709 DOI: 10.1016/j.phrs.2021.105456] [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] [Received: 06/22/2020] [Revised: 12/06/2020] [Accepted: 01/21/2021] [Indexed: 01/10/2023]
Abstract
Formulation of insulin analogs and its delivery are developed in over recent years but glycemic control in most patients with type-1 diabetes mellitus (DM) is not adequate yet. The aim of this meta-analysis is to evaluate the efficacy of dapagliflozin in patients with type-1 DM. The MEDLINE/PubMed, Scopus, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases were searched up to Aug 2020 to identify the potential literature. Random-effects model (DerSimonian and Laird method) was used to estimate the pooled effect size as weighted mean difference (WMD) with 95 % confidence interval (CI). Five randomized placebo-controlled trials with 11 arms were included in the quantitative analysis. The pooled results suggested a significant reduction in glycated hemoglobin A1C (HbA1C; WMD: -0.36 %, 95 % CI: -0.55, -0.18), body weight (WMD: -4.02 kg, 95 % CI: -4.78, -3.25), and total daily insulin dose (TDID; WMD: -10.36 %, 95 % CI: -13.42, -7.29), as well as an increase in 24-h urinary glucose excretion (24-h UGE; WMD: 90.02 g/24-h, 95 % CI: 72.96, 107.09) in dapagliflozin group compared to control group. Dose of dapagliflozin had a significant effect on body weight reduction (Coef = -3.7, p = 0.01) and 24-h UGE (coef = 0.85, p = 0.005). Pooled results of this meta-analysis identified a significant reduction in HbA1c levels, body weight, and TDID, and a substantial increase in 24-h UGE in patients who received dapagliflozin versus placebo.
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Affiliation(s)
- Ahmed Abu-Zaid
- Department of Pharmacology, College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, United States; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | | | - Thusharika Dissanayaka
- Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka; Department of Physiotherapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | | | - Akshaya Srikanth Bhagavathul
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Habeeb Alhabeeb
- Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Amirah Baradhwan
- Department of Medicine, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Sara Alomar
- Department of Family Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
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Clark A, Mohammed AS, Raut A, Moore S, Houlden R, Awad S. Prevalence and Clinical Characteristics of Adults Presenting With Sodium-Glucose Cotransporter-2 Inhibitor-Associated Diabetic Ketoacidosis at a Canadian Academic Tertiary Care Hospital. Can J Diabetes 2020; 45:214-219. [PMID: 33046401 DOI: 10.1016/j.jcjd.2020.08.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In this study, we examined the prevalence and clinical characteristics of sodium-glucose cotransporter-2 inhibitor (SGLT2i)-associated diabetes ketoacidosis (DKA). METHODS A retrospective chart review of patients admitted for DKA over 4 years. Patients with SGLT2i-associated DKA were invited for pancreatic autoantibody testing. A subset of patients were invited for an interview to identify clinical characteristics suggestive of undiagnosed latent autoimmune diabetes in adults (LADA). RESULTS Of 647 DKA admissions, 6.6% were associated with SGLT2i use. Time from SGLT2i initiation and DKA ranged from 2 weeks to 3.25 years; 69.8% had euglycemic DKA. Pancreatic autoantibody testing on 20 patients identified 5 originally diagnosed with type 2 as having LADA. Four were interviewed and had a LADA clinical risk score predictive of this diagnosis. CONCLUSIONS A larger study is needed to qualify the role of the LADA clinical risk score with confirmatory pancreatic autoantibody testing before SGLT2i initiation to reduce DKA risk.
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Affiliation(s)
- Alexa Clark
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Amol Raut
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Moore
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Robyn Houlden
- Division of Endocrinology and Metabolism, Queen's University, Kingston, Ontario, Canada
| | - Sara Awad
- Division of Endocrinology and Metabolism, Queen's University, Kingston, Ontario, Canada.
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5
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Das G. SGLT
inhibitors for type 1 diabetes. PRACTICAL DIABETES 2020. [DOI: 10.1002/pdi.2273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gautam Das
- Endocrinology, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board Merthyr Tydfil UK
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Abstract
Sotagliflozin (Zynquista™) is the first dual inhibitor of sodium-glucose co-transporter-1 and -2 (SGLT1 and 2). In the phase 3, inTANDEM 1-3 trials, adjunctive use of oral sotagliflozin (200 mg or 400 mg once daily) improved glycaemic control and reduced bodyweight and insulin requirements relative to placebo over 24 weeks of treatment in adults whose type 1 diabetes (T1D) was inadequately controlled by insulin therapy. Similar benefits were seen with the drug in patients who were overweight/obese [i.e. body mass index (BMI) ≥ 27 kg/m2] in inTANDEM 1 and 2 (pooled). The benefits of sotagliflozin were largely maintained over 52 weeks of treatment. Overall, use of sotagliflozin in this setting is generally well tolerated and reduces, or at least does not increase, the likelihood of hypoglycaemia; however, as with other SGLT inhibitors, sotagliflozin carries a risk of diabetic ketoacidosis (DKA). On the basis of its risk/benefit profile, sotagliflozin is indicated in the EU as an adjunct to insulin in adults with T1D with a BMI ≥ 27 kg/m2 who have failed to achieve adequate glycaemic control despite optimal insulin therapy, thus expanding the currently limited adjunctive oral treatment options available for use in this population.
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Affiliation(s)
- Emma D Deeks
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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Miyata KN, Zhao S, Wu CH, Lo CS, Ghosh A, Chenier I, Filep JG, Ingelfinger JR, Zhang SL, Chan JSD. Comparison of the effects of insulin and SGLT2 inhibitor on the Renal Renin-Angiotensin system in type 1 diabetes mice. Diabetes Res Clin Pract 2020; 162:108107. [PMID: 32173417 DOI: 10.1016/j.diabres.2020.108107] [Citation(s) in RCA: 8] [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: 02/07/2020] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/22/2023]
Abstract
AIMS SGLT2 inhibitors have been proposed as an adjunct to insulin therapy for glycemic control in type 1 diabetes (T1D) patients. However, concern has been raised due to an increase in renin-angiotensin-system (RAS) activity reported in a clinical trial in which an SGLT2 inhibitor was added while insulin dose was reduced in T1D patients. We previously reported that insulin inhibits intrarenal angiotensinogen (Agt) gene transcription and RAS activation. We hypothesized that insulin, rather than SGLT2 inhibition might regulate the intrarenal RAS. METHODS We compared RAS activity in non-diabetic wild type mice, Akita mice (T1D model) and Akita mice treated with insulin or the SGLT2 inhibitor canagliflozin. RESULTS Treatment of Akita mice with insulin or canagliflozin produced similar reductions in blood glucose, whereas insulin, but not canagliflozin, reduced elevated systolic blood pressure. Akita mice exhibited increased renal Agt mRNA/protein expression, which was attenuated by insulin, but not by canagliflozin. Furthermore, insulin was more effective than canagliflozin in lowering kidney weight and albuminuria. CONCLUSIONS Insulin, but not canagliflozin, lowers intrarenal RAS activity in Akita mice. Our findings can be of potential clinical importance, especially for T1D patients who are not on RAS inhibitors at the time of adding SGLT2 inhibitors.
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Affiliation(s)
- Kana N Miyata
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Shuiling Zhao
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Chin-Han Wu
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Chao-Sheng Lo
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Anindya Ghosh
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Isabelle Chenier
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada
| | - Janos G Filep
- Université de Montréal, Centre de recherche de l'Hopital Maisonneuve-Rosemont, 5415 boul. l'Assomption, Montréal, Quebec H1T 2M4, Canada
| | - Julie R Ingelfinger
- Harvard Medical School, Pediatric Nephrology Unit, Massachusetts General Hospital, 15 Parkman Street, WAC 709, Boston, MA 02114-3117, USA
| | - Shao-Ling Zhang
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada.
| | - John S D Chan
- Département de Médecine, Université de Montréal, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Tour Viger-Pavillon R, 900 Saint Denis Street, Montréal, Quebec H2X 0A9, Canada.
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