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Koceva A, Kravos Tramšek NA. From Sweet to Sour: SGLT-2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis. J Pers Med 2024; 14:665. [PMID: 39063919 PMCID: PMC11277626 DOI: 10.3390/jpm14070665] [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: 06/05/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are highly selective, effective, and generally well-tolerated antihyperglycemic agents targeting the SGLT-2 transmembrane protein. Despite being primarily registered for diabetes treatment, due to their cardiorenal protective properties, SGLT-2 inhibitors caused a paradigm shift in the treatment of other diseases on the cardiorenal spectrum, becoming a fundamental part of heart failure and chronic kidney disease management. With their rapidly increasing use, there are also increased reports of a rare, often under-recognised and potentially deadly side effect, SGLT-2-inhibitor-induced euglycemic diabetic ketoacidosis (EDKA). The primary pathophysiological process behind its multifactorial aetiology comprises glucosuria and osmotic diuresis, which produce a significant carbohydrate deficit, leading to an increase in the glucagon-insulin ratio, thus resulting in accelerated ketogenesis. Although EDKA has a similar clinical presentation as diabetic ketoacidosis (DKA), the absence of the high glucose levels typically expected for DKA and the presence of urine ketone reabsorption contribute to a significant delay in its recognition and timely diagnosis. Given the broad use of SGLT-2 inhibitors, increased awareness, early recognition, and prompt identification of precipitating factors are essential. In this narrative review, we comprehensively explore the pathophysiological mechanisms of SGLT-2-inhibitor-induced EDKA, analyse its clinical manifestation, and identify the most common triggers for its development. We also discuss EDKA management and preventive strategies.
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Affiliation(s)
- Andrijana Koceva
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
| | - Nika Aleksandra Kravos Tramšek
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Wei S, Li Z, Murugappan K, Li Z, Lysevych M, Vora K, Tan HH, Jagadish C, Karawdeniya BI, Nolan CJ, Tricoli A, Fu L. Nanowire Array Breath Acetone Sensor for Diabetes Monitoring. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2309481. [PMID: 38477429 PMCID: PMC11109654 DOI: 10.1002/advs.202309481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/18/2024] [Indexed: 03/14/2024]
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes characterized by the accumulation of ketone bodies in the blood. Breath acetone, a ketone, directly correlates with blood ketones. Therefore, monitoring breath acetone can significantly enhance the safety and efficacy of diabetes care. In this work, the design and fabrication of an InP/Pt/chitosan nanowire array-based chemiresistive acetone sensor is reported. By incorporation of chitosan as a surface-functional layer and a Pt Schottky contact for efficient charge transfer processes and photovoltaic effect, self-powered, highly selective acetone sensing is achieved. The sensor has exhibited an ultra-wide acetone detection range from sub-ppb to >100 000 ppm level at room temperature, covering those in the exhaled breath from healthy individuals (300-800 ppb) to people at high risk of DKA (>75 ppm). The nanowire sensor has also been successfully integrated into a handheld breath testing prototype, the Ketowhistle, which can successfully detect different ranges of acetone concentrations in simulated breath samples. The Ketowhistle demonstrates the immediate potential for non-invasive ketone monitoring for people living with diabetes, in particular for DKA prevention.
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Affiliation(s)
- Shiyu Wei
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Zhe Li
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Krishnan Murugappan
- Commonwealth Scientific and Industrial Research Organisation (CSIRO)Mineral ResourcesPrivate Bag 10Clayton SouthVIC3169Australia
- Nanotechnology Research LaboratoryResearch School of ChemistryCollege of ScienceThe Australian National UniversityCanberraACT2600Australia
| | - Ziyuan Li
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Mykhaylo Lysevych
- Australian National Fabrication FacilityThe Australian National UniversityCanberraACT2600Australia
| | - Kaushal Vora
- Australian National Fabrication FacilityThe Australian National UniversityCanberraACT2600Australia
| | - Hark Hoe Tan
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Chennupati Jagadish
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Buddini I Karawdeniya
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
| | - Christopher J Nolan
- School of Medicine and PsychologyCollege of Health and MedicineThe Australian National UniversityCanberraACT2600Australia
- Department of Diabetes and EndocrinologyThe Canberra HospitalGarranACT2605Australia
| | - Antonio Tricoli
- Nanotechnology Research LaboratoryResearch School of ChemistryCollege of ScienceThe Australian National UniversityCanberraACT2600Australia
- Nanotechnology Research LaboratoryFaculty of EngineeringThe University of SydneyCamperdown2006Australia
| | - Lan Fu
- Australian Research Council Centre of Excellence for Transformative Meta‐Optical SystemsDepartment of Electronic Materials EngineeringResearch School of PhysicsThe Australian National UniversityCanberraACT2600Australia
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O'Brolchain A, Maletsky J, Mian I, Edwards S. Does Treatment with Sodium-Glucose Cotransporter-2 Inhibitors Affect Adherence to International Society Criteria for Diabetic Ketoacidosis in Adult Patients with Type 2 Diabetes? A Retrospective Cohort Analysis. J Diabetes Res 2024; 2024:1849522. [PMID: 38516324 PMCID: PMC10957251 DOI: 10.1155/2024/1849522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 03/23/2024] Open
Abstract
Design Retrospective observational study. Setting. Inpatients at two teaching hospitals in Queensland, Australia. Primary Outcome Measure(s). The number of patients meeting the Joint British Diabetes Society (JBDS) and American Association of Clinical Endocrinology/American College of Endocrinology (AACE/ACE) diagnostic criteria for DKA. Patients were divided into two groups by treatment with SGLT2i at the time of diagnosis. Participants. Adult patients (>18 years old) with type 2 diabetes diagnosed with DKA from April 2015 to January 2022. Patients without type 2 diabetes were excluded. Results One hundred and sixty-five patients were included in this study-comprising 94 patients in the SGLT2i cohort and 70 in the non-SGLT2i cohort. A significantly smaller proportion of patients in the SGLT2i vs. non-SGLT2i cohorts met both JBDS (56% vs. 72%, p = 0.035) and AACE/ACE (63% vs. 82%, p = 0.009) criteria for diagnosis of DKA. Conclusion Patients with type 2 diabetes treated with SGLT2i may be more likely to be diagnosed with DKA despite not meeting the criteria. Despite recent adjustments to account the physiological effects of SGLT2i, significant variation in criteria between major society guidelines presents ongoing challenges to clinicians. The proportion of patients diagnosed using both JDBS and AACE/ACE were comparable, suggesting a reasonable degree of agreement.
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Affiliation(s)
- Aongus O'Brolchain
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
- Griffith University, Queensland, Australia
| | - Joshua Maletsky
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Ibrahim Mian
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Serena Edwards
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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Dwyer KM, Figtree P, Gupta A. Therapeutic carbohydrate restriction and sodium-glucose transporter 2 inhibitors in chronic kidney disease: A potentially powerful combination. Diabetes Obes Metab 2023; 25:2791-2794. [PMID: 37385954 DOI: 10.1111/dom.15195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Karen M Dwyer
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Penny Figtree
- UNSW Medicine & Health, School of Clinical Medicine, Port Macquarie, New South Wales, Australia
| | - Alok Gupta
- Darling Downs Health, Toowoomba, Queensland, Australia
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Oriot P, Hermans MP, Beauloye C, Rogghe PA, Noel S, Paternotte E. Unsuspected diabetic ketoacidosis after myocardial infarction in a patient treated with SGLT2 inhibitor increased length of stay in the hospital: how can it be prevented? A case report. Eur Heart J Case Rep 2023; 7:ytad336. [PMID: 37681058 PMCID: PMC10481769 DOI: 10.1093/ehjcr/ytad336] [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: 02/03/2023] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023]
Abstract
Background As the use of sodium-glucose co-transporter 2 inhibitors (SGLT2is) has expanded beyond glucose-lowering therapy in type 2 diabetes mellitus (T2DM), including chronic kidney disease and heart failure, there has also been an increase in reported cases of diabetic ketoacidosis (DKA) associated with SGLT2i. Case summary A 77-year-old woman with T2DM presented to the emergency department with ST-segment elevation myocardial infarction (MI) complicated by atrial fibrillation. Her medications included empagliflozin, an SGLT2i, initiated for T2DM. Diabetic ketoacidosis was suspected on the basis of a large anion gap, despite a plasma glucose level below 200 mg/dL (11.1 mmol/L) and the absence of symptoms, including nausea and vomiting. Laboratory tests confirmed metabolic acidosis and high ketones. However, the diagnosis of euglycaemic DKA (eu-DKA) was delayed due to lack of symptoms and moderate hyperglycaemia. The patient was successfully treated according to DKA management guidelines. She was discharged on insulin, and SGLT2i was discontinued. Discussion This is a case of asymptomatic eu-DKA after acute MI (AMI). We discuss the use of SGLT2is in AMI and arrhythmias from a review of the literature and the prophylaxis of eu-DKA. Regular monitoring of blood glucose and ketones should be performed in hospitalized T2DM patients treated with SGLT2i. The SGLT2i should be stopped as soon as possible in the event of critical illness or suspected DKA in the setting of an acute illness such as AMI. To help clinicians prevent this potentially fatal disease, we propose a flowchart for the prophylactic management of eu-DKA among inpatients.
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Affiliation(s)
- Philippe Oriot
- Department of Diabetology, Mouscron Hospital Centre, Avenue de Fécamp 49, 7700 Mouscron, Belgium
| | - Michel P Hermans
- Division of Endocrinology & Nutrition, Université catholique de louvain, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium
- IREC – Institut de Recherche Expérimentale et Clinique Avenue Hippocrate, 55 bte B1.55.02 - 1200 Woluwé-Saint-Lambert – Belgium
| | - Christophe Beauloye
- Division of Cardiology, Université catholique de louvain, Avenue Hippocrate 10, 1200 Woluwe-Saint-Lambert, Brussels, Belgium
- IREC – Institut de Recherche Expérimentale et Clinique Avenue Hippocrate, 55 bte B1.55.02 - 1200 Woluwé-Saint-Lambert – Belgium
| | - Pierre-Arnaud Rogghe
- Department of Critical Care Unit, Mouscron Hospital Centre, Avenue de Fécamp 49, 7700 Mouscron, Belgium
| | - Sophie Noel
- Université Catholique de Louvain (UCLouvain), Av Hippocrate 10/2806, B-1200 Brussels, Belgium
| | - Emmanuelle Paternotte
- Department of Cardiology, Mouscron Hospital Centre, Avenue de Fécamp 49, 7700 Mouscron, Belgium
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Stamatiades GA, D'Silva P, Elahee M, Viana GM, Sideri-Gugger A, Majumdar SK. Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter 2 Inhibitors: Clinical and Biochemical Characteristics of 29 Cases. Int J Endocrinol 2023; 2023:6615624. [PMID: 37441367 PMCID: PMC10335870 DOI: 10.1155/2023/6615624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Objective To describe the clinical and biochemical characteristics of all reported cases of DKA associated with SGLT2 inhibitor use in patients with type 2 diabetes mellitus and to identify potential risk factors. Design A retrospective case series was conducted between March 2013 and August 2019 using an electronic medical record search algorithm. Results 25 patients met the criteria for DKA associated with SGLT2i use (total of 29 cases), 15 were female, average age was 54.24 years, and mean diabetes duration was 8.76 years. The majority of the patients (23 patients) had no history of prior DKA. Average blood glucose concentrations at presentation were 298.9 ± 152.7 mg/dl. Interestingly, nearly half of the episodes (14) met the criteria of euglycemic DKA (glucose <250 mg/dl). Average anion gap values were 26.59 ± 6.15 mg/dl, bicarbonate values were 11.14 ± 5.57 mg/dl, and pH values were 7.16 ± 0.12. All had positive serum and urine ketones. The most common presenting symptoms were nausea, vomiting (18 cases), and abdominal pain (10 cases). Common precipitants were poor oral intake (18 cases) and infection (10 cases). A variety of drugs were prescribed along with an SGLT2i, and 11 of the patients were using insulin. None of the cases were fatal. Comparison between euglycemic DKA and hyperglycemic DKA did not identify any significant difference. A major limitation factor of the study was the lack of control group or comparison to other antiglycemic agents to assess the relative risk. Conclusions The majority of SGLT2i-associated DKA cases occurred in patients with T2DM without prior episodes of DKA. The most common presenting symptoms were nausea, vomiting, and abdominal pain, while poor food intake and infection were the main precipitants. Clinicians should consider the possibility of DKA in SGLT2i-treated patients presenting with these symptoms, even in absence of marked hyperglycemia.
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Affiliation(s)
- G A Stamatiades
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - P D'Silva
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
| | - M Elahee
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - G M Viana
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
| | - A Sideri-Gugger
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
- Division of Endocrinology, Columbia University Medical Center, New York, NY 10032, USA
| | - S K Majumdar
- Department of Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
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Oriot P, Aldersons E, Rogghe PA. An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis. Gastroenterology 2023; 164:537-540. [PMID: 36372219 DOI: 10.1053/j.gastro.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Philippe Oriot
- Department of Endocrinology, Mouscron Hospital Center, Mouscron, Belgium.
| | - Elisa Aldersons
- Department of Internal Medicine, Mouscron Hospital Center, Mouscron, Belgium
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He Z, Lam K, Zhao W, Yang S, Li Y, Mo J, Gao S, Liang D, Qiu K, Huang M, Wu J. SGLT-2 inhibitors and euglycemic diabetic ketoacidosis/diabetic ketoacidosis in FAERS: a pharmacovigilance assessment. Acta Diabetol 2023; 60:401-411. [PMID: 36576563 DOI: 10.1007/s00592-022-02015-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
AIMS To investigate the main feature and the association between euglycemic diabetic ketoacidosis (euDKA) /diabetic ketoacidosis (DKA) and sodium-dependent glucose transporters 2 inhibitors (SGLT-2i) from the FDA adverse event reporting system (FAERS). METHODS Cases of SGLT-2i-associated with euDKA/DKA were extracted from the FAERS database and compared with the reports for other hypoglycemia agents (ATC10 class). Disproportionality analyses used the reporting odds ratio (ROR) and information components (IC). The lower limit of the IC 95% credibility interval for IC > 0 is considered a reported signal, with at least 3 cases. RESULTS A total of 10,195 cases of euDKA (n = 1680) and DKA (n = 8515) associated with SGLT-2i were identified from the FAERS. The SGLT-2i was associated with higher reporting of euDKA and DKA compared to other hypoglycemia agents (ROR = 16.69 [95% CI 14.89-18.70], IC = 3.27 [95% CI 2.91-3.66] for euDKA; ROR = 16.44 [95% CI 15.72-17.20], IC = 3.19 [95% CI 3.05-3.34] for DKA). In available data, the median onset time of euDKA/DKA was 31 days, and canagliflozin had the longest onset time (96.5 days for euDKA and 75 days for DKA) compared with dapagliflozin and empagliflozin (p < 0.05). Male patients predominate in euDKA (51.9%), and female patients predominate in DKA (53.7%). Most patients discontinue the treatment (95.5% for euDKA, 93.9% for DKA), and approximately 49.0% (n = 3658) of patients had symptomatic remission after discontinuation of SGLT-2i, and 2.3% (n = 173) of patients had no remission. About 75.6% (n = 6126) of patients need hospitalization after euDKA/DKA. CONCLUSIONS Post-marketing data showed that SGLT-2i was significantly associated with higher reporting of euDKA/DKA. Although euDKA/DKA is rare, clinicians should be aware of SGLT-2i-associated euDKA/DKA events.
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Affiliation(s)
- Zhichao He
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Kakei Lam
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Wenxia Zhao
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Shan Yang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Yu Li
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Jiayao Mo
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China
| | - Siyuan Gao
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Dan Liang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China
| | - Kaifeng Qiu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China.
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, 132 Waihuan East Road, Guangzhou, 511400, People's Republic of China.
| | - Junyan Wu
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, People's Republic of China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, People's Republic of China.
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A Population-Based Study of SGLT2 Inhibitor-Associated Postoperative Diabetic Ketoacidosis in Patients with Type 2 Diabetes. Drug Saf 2023; 46:53-64. [PMID: 36289137 DOI: 10.1007/s40264-022-01247-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION AND OBJECTIVES Operations are a major precipitating factor for sodium-glucose co-transporter 2 inhibitor (SGLT2i)-associated diabetic ketoacidosis (DKA). This study aimed to investigate the risks of SGLT2i-associated postoperative DKA. METHODS We analysed a population-based cohort of patients with type 2 diabetes who underwent operations during 2015-2020. Patients with SGLT2i prescriptions within 6 months before operations were assigned to the SGLT2i group, while others were assigned to the control group. Inverse probability treatment weighting with propensity scores was used to balance the baseline covariates. Postoperative DKA was defined as DKA within 30 days postoperatively. RESULTS Overall, 147,115 subjects were included (3,419 SGLT2i users; 143,696 controls). Preoperative SGLT2i exposure was associated with increased risks of postoperative DKA (incidence = 6.40/1,000 person-years; incidence rate ratio [IRR] 6.33, 95% confidence interval [CI] 5.57-7.18; p < 0.001). Risk factors of SGLT2i-associated postoperative DKA included emergency operation (IRR 24.56, 95% CI 7.42-81.24; p < 0.001), preoperative HbA1c ≥8% (IRR 3.10, 95% CI 1.31-7.33; p = 0.010) and insulin use (IRR 2.88, 95% CI 1.27-6.51; p = 0.011). SGLT2i users who developed postoperative DKA had worse outcomes (invasive mechanical ventilation, dialysis, infections/sepsis, intensive care, and length of hospitalization; p < 0.05) than those who did not, although SGLT2i users who developed postoperative DKA had better outcomes than non-SGLT2i users who developed postoperative DKA (p < 0.05). The risk of postoperative DKA decreased following the implementation of an automatic electronic health record pop-up alert on perioperative precaution regarding SGLT2i (from IRR 4.06 [95% CI 3.41-4.83] to 2.97 [95% CI 2.41-3.65]; p for interaction = 0.020). CONCLUSIONS Preoperative SGLT2i use was associated with increased risks of postoperative DKA in patients with type 2 diabetes. Clinicians could optimize patients' outcomes by appropriate prescription of SGLT2i, while watching out for high-risk features. Implementing automatic electronic health record pop-up alerts may reduce the risk of SGLT2i-associated postoperative DKA.
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Kietaibl AT, Huber J, Clodi M, Abrahamian H, Ludvik B, Fasching P. [Position statement: surgery and diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:256-271. [PMID: 37101047 PMCID: PMC10133078 DOI: 10.1007/s00508-022-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 04/28/2023]
Abstract
This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.
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Affiliation(s)
- Antonia-Therese Kietaibl
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
| | - Joakim Huber
- Interne Abteilung mit Akutgeriatrie und Palliativmedizin, Franziskus Spital, Standort Landstraße, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich.
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich.
| | | | - Bernhard Ludvik
- 1. Medizinische Abteilung für Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
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Inoue A, Katayama A, Sue M, Hasegawa M, Maeda M, Matoba M, Ishii T, Kuribayashi R, Tenta M, Matsushita Y, Takeda M, Iseda I, Wakatsuki T, Hida K. Euglycemic diabetic ketoacidosis in a patient with type 2 diabetes mellitus 3 days after initiating sodium‐glucose cotransporter 2 inhibitor while on an extremely low carbohydrate diet: A case report. Clin Case Rep 2022; 10:e6572. [DOI: 10.1002/ccr3.6572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/26/2022] [Accepted: 10/15/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ayumi Inoue
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Akihiro Katayama
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Mihiro Sue
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Momoka Hasegawa
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Megumi Maeda
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Masaki Matoba
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Takahiro Ishii
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Remi Kuribayashi
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Masafumi Tenta
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Yuichi Matsushita
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Masaya Takeda
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Izumi Iseda
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Toshiyuki Wakatsuki
- Department of Gastroenterology National Hospital Organization, Okayama Medical Center Okayama Japan
| | - Kazuyuki Hida
- Department of Diabetology and Metabolism National Hospital Organization, Okayama Medical Center Okayama Japan
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13
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Han J, Xie S, Jiao H. Sodium-glucose cotransporter-2 inhibitor-induced euglycemic diabetic ketoacidosis: A case report. J Clin Pharm Ther 2022; 47:1482-1485. [PMID: 35949163 DOI: 10.1111/jcpt.13737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 12/19/2022]
Affiliation(s)
- Jingjing Han
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Shuo Xie
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Hongmei Jiao
- Department of Geriatrics, Peking University First Hospital, Beijing, China
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14
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Mehta PB, Robinson A, Burkhardt D, Rushakoff RJ. Inpatient perioperative euglycemic DKA due to SGLT2 inhibitors - lessons from a case series and strategies to decrease incidence. Endocr Pract 2022; 28:884-888. [PMID: 35753675 DOI: 10.1016/j.eprac.2022.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/04/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Identify clinical characteristics and factors associated with development of euglycemic diabetic ketoacidosis (eDKA), and develop strategies to reduce such events. METHODS Electronic health record (EHR) data was extracted to identify all patients between 12/1/2013 and 3/30/2021 who underwent procedures and had been prescribed a sodium-glucose co-transporter 2 inhibitor (SGLT2i) prior to these procedures. The resulting list was streamlined to a subset of patients who either had diabetic ketoacidosis (DKA) listed as a hospital diagnosis, post-operative serum bicarbonate ≤ 16 mmol/L, or post-operative serum pH ≤ 7.20. Clinical documentation and laboratory data was reviewed to determine those with eDKA. RESULTS A total of 2183 procedures (on 1307 patients) met extraction criteria with the majority (1726, 79.1%) being non-emergent. Among the 1307 patients, 625 (47.8%) were prescribed empagliflozin, 447 (34.2%) canagliflozin, 214 (16.4%) dapagliflozin, and 21 (1.6%) ertugliflozin. Eight incidences of eDKA were noted on 8 unique patients; 5 had undergone emergent and 3 had undergone non-emergent procedures. In the 3 non-emergent cases, only 1 patient had received counseling to stop the SGLT2i three days prior to the procedure. In perioperative patients who were prescribed an SGLT2i over a six-year period, the incidence of eDKA was 0.17% for non-emergent procedures and 1.1% for emergent procedures. CONCLUSION Euglycemic DKA was rare in patients undergoing non-emergent procedures, likely due to pre-operative instructions to stop their SGLT2i three days prior to the procedure. Euglycemic DKA was more likely to occur in patients undergoing emergent surgery, when the SGLT2i could not be prophylactically stopped.
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Affiliation(s)
- Paras B Mehta
- University of California, San Francisco, United States.
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Affiliation(s)
- Eugene Braunwald
- From the TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and the Department of Medicine, Harvard Medical School, Boston
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16
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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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