Cétose ou acidocétose diabétique euglycémique chez des patients diabétiques de type 2 traités par inhibiteurs du SGLT2 : une série de cas cliniques en Belgique

Euglycemic diabetic ketoacidosis in a patient with acute stroke taking sodium glucose co-transporter 2 inhibitor

Introduction

Diabetic Ketoacidosis is characterized by a triad of metabolic acidosis, hyperglycemia, and ketonemia. It is a medical emergency that needs urgent and aggressive management. In some cases, the blood glucose level may be relatively normal. Such a condition is known as Euglycemic Diabetic Ketoacidosis.

Case presentation

We present a case of Euglycemic Diabetic Ketoacidosis, who was initially brought to the emergency room with the features of acute stroke. There was a diagnostic dilemma among the treating physicians due to his relatively normal blood glucose levels while he developed ketoacidosis.

Discussion

Presentation of the patients includes similar to DKA such as nausea, vomiting, malaise, fatigue, and Kussmaul's respiration. The diabetic patients under sodium glucose co-transporter-2 inhibitor therapy may develop it under the setting of different precipitating factors like infection, trauma/surgery, strenuous physical exercise, fasting, alcohol intake and acute vascular events.

Conclusion

Euglycemic DKA is a rare condition and its diagnosis is a challenging task. So, we should always consider it as a differential whenever any diabetic patient shows with increased anion gap metabolic acidosis with or without typical symptoms and signs. Also, we need to be aware to discontinue of SGLT-2 medication during the time of infection, surgery, severe trauma, acute illness and dehydration in the diabetic patients.

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Diabetic Ketoacidosis is a medical emergency with a triad of metabolic acidosis, hyperglycemia and ketonemia.

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The precipitating factors includes infection, surgery, fasting, alcohol intake, acute vascular events, trauma and prolonged physical exercise.

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Patient presents with complaints similar to DKA such as nausea, vomiting, malaise, fatigue, and Kussmaul's respiration.

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Management includes fluid resuscitation, insulin infusion, dextrose and potassium supplementation.

Euglycemic diabetic ketoacidosis in a patient with type 1 diabetes and SARS-CoV-2 pneumonia: case-report and review of the literature

OBJECTIVE

Recent publications on Coronavirus Disease-2019 (COVID-19) report that diabetic people with or without co-morbidities are at higher risk of developing severe and/or fatal illnesses.

METHOD AND RESULT

We report the first case of a 60-year-old man with a 27-year history of type 1 diabetes mellitus, infected by SARS-CoV-2 presenting with an euglycaemic ketoacidosis and an acute respiratory distress syndrome.

CONCLUSION

This case report reminds us of the importance of adjusting more recent glucose-lowering drugs, including sodium-glucose cotransporter 2 inhibitors, in the overall management of type 1 diabetic individuals during the ongoing COVID-19 outbreak.

ABBREVIATIONS

COVID-19: Coronavirus disease 2019 (SARS-CoV-2) virus, T1DM: Type 1 diabetes mellitus, T2DM: Type 2 diabetes mellitus, SGLT2i: Sodium-glucose cotransporter 2 inhibitor, DKA: diabetic ketoacidosis, euDKA: euglycaemic diabetic ketoacidosis.

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

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.

SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort

Euglycemic diabetic ketoacidosis (EuDKA) secondary to Sodium-glucose co-transporter-2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2D) is a rare but increasingly reported phenomenon. Not much is known about the burden of EuDKA in patients on SGLT2i or the associated factors. This retrospective cohort study tries to delineate the differences in factors associated with the development of EuDKA as compared to hyperglycemic DKA. We conducted a multicentre, retrospective study across three tertiary care centers under Weill Cornell affiliated-Hamad Medical Corporation, Qatar. The cohort comprised of T2D patients on SGLT2i who developed DKA between January 2015 to December 2020. The differences between the subjects who developed EuDKA or hyperglycaemic DKA (hDKA) were analyzed. A total of 9940 T2D patients were on SGLT2i during 2015–2020, out of which 43 developed DKA (0.43%). 25 developed EuKDA, whereas 18 had hDKA. The point prevalence of EuDKA in our cohort was 58.1%. EuDKA was most common in patients using canagliflozin, followed by empagliflozin and Dapagliflozin (100%, 77%, and 48.3%, respectively). Overall, infection (32.6%) was the most common trigger for DKA, followed by insulin non-compliance (13.7%). Infection was the only risk factor with a significant point estimate between the two groups, being more common in hDKA patients (p-value 0.006, RR 2.53, 95% CI 1.07–5.98). Canagliflozin had the strongest association with the development of EuDKA and was associated with the highest medical intensive care unit (MICU) admission rates (66.6%). In T2D patients on SGLT2i, infection is probably associated with an increased risk of developing EuDKA. The differential role of individual SGLT2i analogs is less clear and will need exploration by more extensive prospective studies.

Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis

Aims

COVID-19 is associated with diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and euglycaemic DKA (EDKA); however, evidence regarding parameters affecting outcome and mortality rates is scarce.

Methods

A systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January 2020 to 7 January 2021 to identify all studies describing clinical profile, outcome and mortality rates regarding DKA, HHS, DKA/HHS and EDKA cases in COVID-19 patients. The appropriate Joanna Briggs Institute tools were used for quality assessment; quality of evidence was approached using GRADE. Univariate and multivariate analyses were used to assess correlations between clinical characteristics and outcome based on case reports. Combined mortality rates (CMR) were estimated from data reported in case report series, cross-sectional studies, and meta-analyses. The protocol was submitted to PROSPERO (ID: 229356/230737).

Results

From 312 identified publications, 44 were qualitatively and quantitatively analyzed. Critical COVID-19 necessitating ICU (P = 3 × 10^–8), DKA/HHS presence (P = 0.021), and AKI (P = 0.037) were independently correlated with death. Increased COVID-19 severity (P = 0.003), elevated lactates (P < 0.001), augmented anion gap (P < 0.001), and AKI (P = 0.002) were associated with DKA/HHS. SGLT-2i were linked with EDKA (P = 0.004) and negatively associated with AKI (P = 0.023). CMR was 27.1% (95% CI 11.2–46.9%) with considerable heterogeneity (I² = 67%).

Conclusion

Acute diabetes-related metabolic emergencies in COVID-19 patients lead to increased mortality; key determinants are critical COVID-19 illness, coexistence of DKA/HHS and AKI. Previous SGLT-2i treatment, though associated with EDKA, might preserve renal function in COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-021-00502-9.

Caring for patients with diabetes during COVID-19 pandemic: Important considerations for pharmacists

The current pandemic of the COVID-19 infection, coupled with the increased global burden of diabetes, has imposed significant challenges to the healthcare providers in providing effective and sustained care to patients with diabetes during the ongoing pandemic. It is, therefore, important for healthcare providers to understand and follow the recommended changes in the delivery of care, lifestyle modifications, and pharmacotherapy to ensure optimal care to the patients during and post-pandemic era. This commentary aims to discuss the impact of COVID-19 on diabetes care and the important considerations for pharmacists during this pandemic.