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Kuchay MS, Khatana P, Mishra M, Surendran P, Kaur P, Wasir JS, Gill HK, Singh A, Jain R, Kohli C, Bakshi G, Radhika V, Saheer S, Singh MK, Mishra SK. Dapagliflozin for inpatient hyperglycemia in cardiac surgery patients with type 2 diabetes: randomised controlled trial (Dapa-Hospital trial). Acta Diabetol 2023; 60:1481-1490. [PMID: 37380728 DOI: 10.1007/s00592-023-02138-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
AIMS To examine the efficacy and safety of dapagliflozin in the treatment of hyperglycemia in cardiac surgery patients with type 2 diabetes (T2D). METHODS Cardiac surgery patients with T2D (n = 250) were randomly assigned (1:1) to receive dapagliflozin plus basal-bolus insulin (DAPA group) or basal-bolus insulin alone (INSULIN group) in the early postoperative period. The primary outcome was mean difference in daily blood glucose (BG) concentrations between groups. The major safety outcomes were the occurrence of severe ketonemia/diabetic ketoacidosis (DKA) and hypoglycemia. All analyses were performed according to the intention-to-treat principle. RESULTS The median age of the patients was 61 years (range, 55-61), and 219 (87.6%) were men. Overall, the randomization blood glucose was 165 mg/dL (SD, 37) and glycated hemoglobin was 7.7% (SD, 1.4). There were no differences in mean daily BG concentrations (149 vs. 150 mg/dL), mean percentage of readings within target BG of 70-180 mg/dL (82.7% vs. 82.5%), total daily insulin dose (mean, 39 vs. 40 units/day), number of daily insulin injections (median, 3.9 vs. 4), length of hospital stay (median, 10 vs. 10 days), or hospital complications (21.6% vs. 24.8%) between the DAPA and INSULIN groups. The mean plasma ketone levels were significantly higher in the DAPA group than in the INSULIN group at day 3 (0.71 vs. 0.30 mmol/L) and day 5 (0.42 vs. 0.19 mmol/L) of randomization. Six patients in the DAPA group developed severe ketonemia, but no patient developed DKA. There were no differences in the proportion of patients with BG < 70 mg/dL (9.6% vs. 7.2%) between the two groups. CONCLUSION Dapagliflozin complementary to basal-bolus insulin does not improve glycemia further over and above the basal-bolus insulin alone in hospitalized cardiac surgery patients. Dapagliflozin significantly increases plasma ketones levels. Safety of dapagliflozin in hospitalized patients needs further investigation. Trial registration ClinicalTrials.gov NCT05457933.
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Affiliation(s)
- Mohammad Shafi Kuchay
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India.
| | - Pushpender Khatana
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Mitali Mishra
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Parvathi Surendran
- ICMR - National Institute of Epidemiology, Ayapakkam, Ambattur, Chennai, Tamil Nadu, 600077, India
| | - Parjeet Kaur
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Jasjeet Singh Wasir
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Harmandeep Kaur Gill
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Apanshu Singh
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Rujul Jain
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Chhavi Kohli
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Gazal Bakshi
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Vishnupriya Radhika
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Sumayya Saheer
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Manish Kumar Singh
- Department of Clinical Research and Studies, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Sunil Kumar Mishra
- Division of Endocrinology and Diabetes, Medanta-The Medicity Hospital, Gurugram, Haryana, 122001, India
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Euglycemic diabetic ketoacidosis (EDKA) after pancreaticoduodenectomy: An under-recognized metabolic abnormality with outcome implications. Surgery 2023; 173:888-893. [PMID: 36028380 DOI: 10.1016/j.surg.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/22/2022] [Accepted: 07/11/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis is a metabolic condition characterized by relative euglycemia, ketonemia, and metabolic acidosis that occurs through mechanisms resembling starvation. Pancreaticoduodenectomy is a complex abdominal operation that subjects patients to a prolonged fasting and an inflammatory state. This study examined the incidence of euglycemic diabetic ketoacidosis and potential opportunities for early diagnosis and management in patients undergoing pancreaticoduodenectomy. METHODS A single-institution retrospective review of 350 patients who underwent pancreaticoduodenectomy between 2017 and 2020 was performed. Primary endpoints were peak beta-hydroxybutyrate levels, peak lactate levels, lowest pH, peak base deficits, and urinary output within the first 24 hours, postoperatively. Additional endpoints included incidence of postoperative pancreatic fistula, delayed gastric emptying, total complications, postoperative hospital length of stay, readmission rates, and changes in insulin regimen at discharge. RESULTS Of the 350 cases reviewed, 39 (11.1%) patients developed euglycemic diabetic ketoacidosis. Male sex and pancreatic cancer were associated with a risk for euglycemic diabetic ketoacidosis (P < .05). Patients with euglycemic diabetic ketoacidosis had significantly higher peak beta-hydroxybutyrate levels than patients without euglycemic diabetic ketoacidosis (mean difference = 19.8 mg/dL, 95% confidence interval = 14.7-24.9, P < .001), and were nearly four times more likely to require insulin at discharge (odds ratio 3.8, 95% confidence interval = 1.1-13.0, P < .05). CONCLUSION This is the first large descriptive study that investigates euglycemic diabetic ketoacidosis after pancreaticoduodenectomy. Euglycemic diabetic ketoacidosis after pancreaticoduodenectomy is associated with significantly higher beta-hydroxybutyrate levels and new or increased insulin requirement at discharge. Our study demonstrates potential markers for euglycemic diabetic ketoacidosis after pancreaticoduodenectomy, offering an opportunity to identify and successfully treat this disease in a timely manner.
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Sodium-glucose cotransporter 2 inhibitor-associated perioperative ketoacidosis: a systematic review of case reports. J Anesth 2023; 37:465-473. [PMID: 36849747 DOI: 10.1007/s00540-023-03174-8] [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: 09/21/2022] [Accepted: 02/18/2023] [Indexed: 03/01/2023]
Abstract
Although the recommended preoperative cessation period for sodium-glucose cotransporter 2 inhibitors (SGLT2is) changed in 2020 (from 24 h to 3-4 days preoperatively) to reduce the risk of SGLT2i-associated perioperative ketoacidosis (SAPKA), the validity of the new recommendation has not been verified. Using case reports, we assessed the new recommendation effectiveness and extrapolated precipitating factors for SAPKA. We searched electronic databases up to June 1, 2022 to assess SAPKA (blood pH < 7.3 and blood or urine ketone positivity within 30 days postoperatively in patients taking SGLT2i). We included 76 publications with 99 cases. The preoperative SGLT2i cessation duration was reported for 59 patients (59.6%). In all cases with available cessation periods, the SGLT2is were interrupted < 3 days preoperatively. No SAPKA cases with > 2-day preoperative cessation periods were found. Many case reports lack important information for estimating precipitating factors, including preoperative SGLT2i cessation period, body mass index, baseline hemoglobin A1c level, details of perioperative fluid management, and type of anesthesia. Our study suggested that preoperative SGLT2i cessation for at least 3 days could prevent SAPKA. Large prospective epidemiologic studies are needed to identify risk factors for SAPKA.
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Branco A, Fatima R, Liblik K, Jackson R, Payne D, El-Diasty M. Euglycemic DKA Associated with SGLT2 Inhibitors after Cardiac Surgery, Review of Current Literature. J Cardiothorac Vasc Anesth 2022; 36:3877-3886. [DOI: 10.1053/j.jvca.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022]
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Kietaibl AT, Fasching P, Glaser K, Petter-Puchner AH. New Diabetic Medication Sodium-Glucose Cotransporter-2 Inhibitors Can Induce Euglycemic Ketoacidosis and Mimic Surgical Diseases: A Case Report and Review of Literature. Front Surg 2022; 9:828649. [PMID: 35402477 PMCID: PMC8987984 DOI: 10.3389/fsurg.2022.828649] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/23/2022] [Indexed: 12/24/2022] Open
Abstract
Background Euglycemic diabetic ketoacidosis (EDKA) is a potentially life-threatening condition and a reported side effect of antidiabetic sodium-glucose-cotransporter-2-inhibitors (SGLT2-I). The analysis of the herein presented case and its management formed the incentive to prepare this multidisciplinary work and includes an overview about perioperative SGLT2-I-induced ketoacidosis. Method A PubMed search on relevant entries was conducted combining the terms "euglycemic diabetic ketoacidosis" AND "surgery." Results A total of 33 articles on SGLT2-I-induced ketoacidosis in the context of surgical treatment were identified. According to this literature research risk factors for the development are infection, perioperative fasting, surgical stress, and insulin dose reduction. Conclusion Unspecific symptoms mimicking acute abdomen and normoglycemia can lead to delayed diagnosis of EDKA and might harm patients under SGLT2-I therapy in the perioperative setting. SGLT2-I medication should be withheld for at least 24-48 h prior to surgery according to this review of literature and restarted only in stable clinical conditions to avoid the severe complication of EDKA.
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Affiliation(s)
- Antonia-Therese Kietaibl
- Department of 5th Internal Medicine With Endocrinology, Rheumatology and Geronotology With Outpatient Department, Clinic Ottakring, Vienna, Austria
| | - Peter Fasching
- Department of 5th Internal Medicine With Endocrinology, Rheumatology and Geronotology With Outpatient Department, Clinic Ottakring, Vienna, Austria
| | - Karl Glaser
- Department of General-, Oncologic- and Visceral Surgery, Clinic Ottakring, Vienna, Austria
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