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

13. Older Adults: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Evolving Clinical Features of Diabetic Ketoacidosis: The Impact of SGLT2 Inhibitors

Background/Objectives: The antidiabetic effect of SGLT2 inhibitors (SGLT2-is) is based on their ability to increase glucose excretion through urine by inhibiting the kidney-resident SGLT2 protein. Euglycemic diabetic ketoacidosis (EuDKA) is an uncommon but potentially life-threatening adverse effect of these medications, which are notable for their antidiabetic, cardiovascular, and renal protective properties. This study aimed to clarify the impact of SGLT2-is on demographic, clinical, and biochemical characteristics in patients with DKA. Methods: A total of 51 individuals with a diagnosis of DKA were included in the trial; 19 of these patients were treated with SGLT2-is, while 32 were not. Patients diagnosed with DKA and treated with SGLT2-is were compared to those not treated with the medication in terms of clinical, biochemical, and laboratory characteristics. Results: The age of patients utilizing SGLT2-is was statistically considerably greater than that of non-users (p < 0.001). EuDKA was exclusively noted in the SGLT2-is cohort (p = 0.005). Urinary tract infections, vulvovaginitis, and genitourinary infections were substantially more prevalent among SGLT2-i users compared with non-users among both women and the overall patient group (p = 0.036, p = 0.001, p = 0.005, p = 0.003, respectively). Plasma glucose concentrations were significantly higher in SGLT2-i non-users (p = 0.006). Chloride (Cl-) concentrations were elevated among SGLT2-i users (p = 0.036). Conclusions: The study findings indicate that SGLT2 inhibitors may substantially influence age, serum chloride, EuDKA, and the occurrence of genitourinary infections in individuals with DKA.

Diabetic Ketoacidosis as an Effect of Sodium-Glucose Cotransporter 2 Inhibitor: Real World Insights

One of the notable adverse effects of sodium-glucose cotransporter 2 (SGLT2) inhibitor is diabetic ketoacidosis (DKA) often characterized by euglycemia. In this retrospective review of patients with DKA from 2015 to 2023, 21 cases of SGLT2 inhibitorassociated DKA were identified. Twelve (57.1%) exhibited euglycemic DKA (euDKA) while nine (42.9%) had hyperglycemic DKA (hyDKA). More than 90% of these cases were patients with type 2 diabetes mellitus. Despite similar age, sex, body mass index, and diabetes duration, individuals with hyDKA showed poorer glycemic control and lower C-peptide levels compared with euDKA. Renal impairment and acidosis were worse in the hyDKA group, requiring hemodialysis in two patients. Approximately one-half of hyDKA patients had concurrent hyperosmolar hyperglycemic state. Common symptoms included nausea, vomiting, general weakness, and dyspnea. Seizure was the initial manifestation of DKA in two cases. Infection and volume depletion were major contributors, while carbohydrate restriction and inadequate insulin treatment also contributed to SGLT2 inhibitor-associated DKA. Despite their beneficial effects, clinicians should be vigilant for SGLT2 inhibitor risk associated with DKA.

From Hospital to Home: Evidence-Based Care for Worsening Heart Failure

Heart failure (HF) is a leading cause of hospitalization in older adults. Patients are at high risk of readmission and death following hospitalization for HF. There is no standard approach of health care delivery during the hospital-to-home transition period, leaving missed opportunities in care optimization. In this review, we discuss contemporary randomized clinical trials that tested decongestion strategies, disease-modifying therapies, and health care services that inform the care of patients with worsening HF. We provide evidence-informed recommendations for optimizing therapies and improving outcomes during and following hospitalization for HF. These include adequate decongestion with loop diuretics and select sequential nephron blockade strategies based on early evaluation of diuretic response; initiation of disease-modifying pharmacotherapies prior to hospital discharge with close follow-up and optimization after discharge; cardiac rehabilitation; and transitional or palliative care referral post-hospitalization. Evidence-based implementation strategies to facilitate broad uptake include digital health tools and algorithm-driven optimization of pharmacotherapies.

Management of Diabetes Mellitus in Acromegaly and Cushing's Disease with Focus on Pasireotide Therapy: A Narrative Review

Patients suffering from acromegaly and Cushing's Disease (CD) face the risk of several clinical complications. The onset of diabetes mellitus (DM) is among the most important: exposure to elevated growth hormone or cortisol levels is associated with insulin resistance (IR). DM contributes to increasing cardiovascular risk for these subjects, which is higher compared to healthy individuals. Hyperglycemia may also be caused by pasireotide, a second-generation somatostatin receptor ligand (SRLs), currently used for the treatment of these diseases. Accordingly, with 2014 medical expert recommendations, the management of hyperglycemia in patients with CD and treated with pasireotide is based on lifestyle changes, metformin, DPP-4 inhibitors (DPP-4i) and, subsequently, GLP-1 Receptor Agonists (GLP-1 RAs). There is no position for SGLT2-inhibitors (SGLT2-i). However, a very recent experts' consensus regarding the management of pasireotide-induced hyperglycemia in patients with acromegaly suggests the use of GLP-1 RAs as first line treatment (in suitable patients) and the use of SGLT2-i as second line treatment in patients with high cardiovascular risk or renal disease. As a matter of fact, beyond the hypoglycemic effect of GLP1-RAs and SGLT2-i, there is increasing evidence regarding their role in the reduction of cardiovascular risk, commonly very high in acromegaly and CD and often tough to improve despite biochemical remission. So, an increasing use of GLP1-RAs and SGLT2-i to control hyperglycemia is desirable in these diseases. Obviously, all of that must be done with due attention in order to minimize the occurrence of adverse events. For this reason, large studies are needed to analyze the presence of potential limitations.

From Sweet to Sour: SGLT-2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis

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.

Ketoacidosis and SGLT2 Inhibitors: A Narrative Review

An acute metabolic complication of diabetes mellitus, especially type 1, is diabetic ketoacidosis (DKA), which is due to an increase in blood ketone concentrations. Sodium/glucose co-transporter-2 inhibitor (SGLT2-i) drugs have been associated with the occurrence of a particular type of DKA defined as euglycemic (euDKA), characterized by glycemic levels below 300 mg/dL. A fair number of euDKA cases in SGLT2-i-treated patients have been described, especially in the last few years when there has been a significant increased use of these drugs. This form of euDKA is particularly insidious because of its latent onset, associated with unspecific symptomatology, until it evolves (progressing) to severe systemic forms. In addition, its atypical presentation can delay diagnosis and treatment. However, the risk of euDKA associated with SGLT2-i drugs remains relatively low, but it is essential to promptly diagnose and manage it to prevent its serious life-threatening complications. In this narrative review, we intended to gather current research evidence on SGLT2i-associated euDKA from randomized controlled trials and real-world evidence studies, its diagnostic criteria and precipitating factors.

Understanding the Complexity of Hyperglycemic Emergencies: Exploring the Influence of the Type and Duration of Diabetes Mellitus and Its Impact on Mortality

Background Diabetes mellitus remains a pressing global health issue, characterized by chronic metabolic dysfunction and the potential for life-threatening acute hyperglycemic emergencies. These emergencies, known as diabetic ketoacidosis and hyperosmolar hyperglycemic states, trigger a series of physiological disruptions. This article delves deeply into how the type and duration of diabetes mellitus affect the occurrence of hyperglycemic emergencies and mortality rates. Methods The study was conducted at the Institute of Internal Medicine, Rajiv Gandhi General Hospital, affiliated with Madras Medical College, spanning from July 2021 to December 2021. It encompassed both individuals newly diagnosed with diabetic ketoacidosis and patients already undergoing diabetic treatment who developed diabetic ketoacidosis and hyperosmolar hyperglycemic states. Results Within the study cohort of 110 patients, 37.27% were diagnosed with Type 1 diabetes mellitus, while 62.73% were classified as Type 2 diabetes mellitus patients. Among these individuals, 23.60% were newly diagnosed with diabetes, 22.70% had been diabetic for less than one year, 47.30% had a diabetic history of two to five years, and 6.40% had been diabetic for over six years. However, upon investigating the relationship between diabetes duration and mortality rate, no statistically significant findings were observed. Conclusion Hyperglycemic emergencies represent multifaceted clinical challenges influenced by the interplay of various factors, including the type and duration of the disease. By maintaining effective management of hyperglycemia from the outset and sustaining it throughout their lives, people with diabetes can improve their physical and mental health and reduce the likelihood of developing long-term complications that may negatively impact their overall well-being.

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

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.

Drug Safety Evaluation of Sodium-Glucose Cotransporter 2 Inhibitors in Diabetic Comorbid Patients by Review of Systemic Extraglycemic Effects

Purpose

The aim of this study is to evaluate the safety of this drug in diabetic patients with comorbidities of all systems.

Method

In this review, the beneficial effects of this drug and its mechanism on the disorders of every system of humans in relation to diabetes have been studied, and finally, its adverse effects have also been discussed. The search for relevant information is carried out in the PubMed and Google Scholar databases by using the following terms: diabetes mellitus type 2, SGLT, SGLT2 inhibitors, (SGLT2 inhibitors) AND (Pleiotropic effects). All English-published articles from 2016 to 2023 have been used in this study. It should be noted that a small number of articles published before 2016 have been used in the introduction and general informations.

Results

Its beneficial effects on improving cardiovascular disease risk factors and reducing adverse events caused by cardiovascular and renal diseases have proven in most large clinical studies that these effects are almost certain. It also has beneficial effects on other human systems such as the respiratory system, the gastrointestinal system, the circulatory system, and the nervous system; more of them are at the level of clinical and pre-clinical trials but have not been proven in large clinical trials or meta-analyses.

Conclusion

With the exception of a few adverse effects, this drug is considered a good choice and safe for all diabetic patients with comorbidities of all systems.

Sodium-Glucose Cotransporter 2 Inhibitor (SGLT2i) Associated Diabetic Ketoacidosis in Oncology Patients: A Case Series and Literature Review

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). The clinical data regarding the use of SGLT2i and its potential side effects in oncology patients is limited. We are retrospectively reporting four oncology patients with type 2 diabetes mellitus using SGLT2i who were admitted with DKA. The mean age of the patients was 61.25 years, and male to female ratio was 1:1. The duration of type 2 diabetes ranged from 10 to 20 years (mean 15.75 years) and the types of SGLT2i used were empagliflozin 25 mg and dapagliflozin 10 mg. The types of malignancy in our case series included squamous cell carcinoma of the cheek, ovarian cancer, and two patients had laryngeal carcinoma (squamous cell carcinoma). Diabetic ketoacidosis was diagnosed in three patients following chemotherapy or concurrent chemo-radiotherapy. Poor oral intake and infections were the main risk factors in our patients. Mean blood glucose level, anion gap, and bicarbonate level were 11.7 mmol/l, 32.25, and 5 mmol/l, respectively. The majority had moderate DKA based on pH (mean 7.13). The hospital course was complicated by acute kidney injury (n=4), infections (n=4) (urinary tract infections, and pneumonia), and three patients required critical care. The mean length of hospitalization was 19.2 days and no mortality was reported among our patients. SGLT2i-related DKA is an emerging complication recognized in oncology patients. Some of the risk factors for this complication are starvation, poor oral intake, and infection which are quite prevalent in oncology patients. Temporary holding of SGLT2i medication during this period might have a potential preventive role.

Perioperative Management of Patients Receiving Sodium-Glucose Cotransporter 2 Inhibitors: Development of a Clinical Guideline at a Large Academic Medical Center

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology, and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.

The risk factors of diabetic ketosis and diabetic ketoacidosis among patients with type 2 diabetes mellitus treated with SGLT2 inhibitors: a retrospective study

BACKGROUND

There is limited evidence on the safety of sodium-glucose co-transporter-2 inhibitor (SGLT2i) use in the real world of China. We conducted this two-center, retrospective study to assess the incidence rate and risk factors of Dapagliflozin-associated DK/DKA among patients with type 2 diabetes mellitus (T2DM) in China.

RESEARCH DESIGN AND METHODS

Patients with T2DM treated with Dapagliflozin in Shanghai General Hospital were included in this retrospective analysis. Univariate and multivariate logistic regression was performed, and odds ratio (OR) and 95% confidence interval (CI) were calculated to identify the influencing factors associated with the occurrence of DK/DKA.

RESULTS

A total of 1985 T2DM patients received Dapagliflozin for the first time were included. The prevalence of DK and DKA was 2.47% and 0.35%, respectively. Multivariate logistic regression identified age <45 years [OR = 2.99, 95% CI (1.45-6.17)], concomitant use of Acarbose [OR = 2.18, 95% CI (1.06-3.38)], Metformin [OR = 1.84, 95% CI (1.01-3.38)], and Insulin [OR = 1.93, 95% CI (1.02-3.66)] as participating factors for DK/DKA. The 1:4 matched subset sensitivity analysis further confirmed the risk factors of Dapagliflozin-associated DK/DKA.

CONCLUSIONS

Age less than 45 years, concomitant use of Acarbose and insulin were risk factors for Dapagliflozin-associated DK/DKA. Clinicians should watch out for high-risk features among patients with SGLT2i prescription.

Potential Underlying Mechanisms Explaining the Cardiorenal Benefits of Sodium-Glucose Cotransporter 2 Inhibitors

There is a bidirectional pathophysiological interaction between the heart and the kidneys, and prolonged physiological stress to the heart and/or the kidneys can cause adverse cardiorenal complications, including but not limited to subclinical cardiomyopathy, heart failure and chronic kidney disease. Whilst more common in individuals with Type 2 diabetes, cardiorenal complications also occur in the absence of diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially approved to reduce hyperglycaemia in patients with Type 2 diabetes. Recently, these agents have been shown to significantly improve cardiovascular and renal outcomes in patients with and without Type 2 diabetes, demonstrating a robust reduction in hospitalisation for heart failure and reduced risk of progression of chronic kidney disease, thus gaining approval for use in treatment of heart failure and chronic kidney disease. Numerous potential mechanisms have been proposed to explain the cardiorenal effects of SGLT2i. This review provides a simplified summary of key potential cardiac and renal mechanisms underlying the cardiorenal benefits of SGT2i and explains these mechanisms in the clinical context. Key mechanisms related to the clinical effects of SGLT2i on the heart and kidneys explained in this publication include their impact on (1) tissue oxygen delivery, hypoxia and resultant ischaemic injury, (2) vascular health and function, (3) substrate utilisation and metabolic health and (4) cardiac remodelling. Knowing the mechanisms responsible for SGLT2i-imparted cardiorenal benefits in the clinical outcomes will help healthcare practitioners to identify more patients that can benefit from the use of SGLT2i.

Efficacy and Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Nondiabetic Patients with Chronic Kidney Disease: A Review of Recent Evidence

Background

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed as glucose-lowering agents in patients with type-2 diabetes. However, available data from clinical trials and meta-analyses suggest that SGLT2i have pleiotropic benefits in reducing mortality and delaying the progression of chronic kidney disease (CKD) in both diabetic and nondiabetic patients. Thus, we herein review the current evidence regarding the efficacy and safety of SGLT2i in patients with nondiabetic CKD and appraise the recently reported clinical trials that might facilitate the management of CKD in routine clinical practice.

Summary

The benefits of SGLT2i on nondiabetic CKD are multifactorial and are mediated by a combination of mechanisms. The landmark DAPA-CKD trial revealed that dapagliflozin administered with renin-angiotensin system blockade drugs reduced the risk of a sustained decline (at least 50%) in the estimated glomerular filtration rate, end-stage kidney disease, or death from cardiorenal causes. The recent EMPA-KIDNEY trial showed that empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes. These benefits were consistent in patients with and without diabetes. Moreover, a meta-analysis of DAPA-HF and EMPEROR-Reduced trials confirmed reductions in the combined risk of cardiovascular death or worsening heart failure including composite renal endpoint.

Key Messages

Considering the robust data available from DAPA-CKD, EMPA-KIDNEY, and other trials such as EMPEROR-Preserved, DIAMOND that included nondiabetic patients, it may be necessary to update current guidelines to include SGLT2i as a first-line therapy for CKD and reevaluate current CKD therapeutic approaches.

A Case of Prolonged Recovery for Post-percutaneous Coronary Intervention (PCI) Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a 28-Year-Old

Euglycemic diabetic ketoacidosis (DKA) is a rare, but clinically important, presentation that can lead to significant morbidity and mortality in patients with diabetes mellitus. It has been associated with multiple etiologies, including sodium-glucose cotransport-2 (SGLT2) inhibitor use. This case report details the presentation of a 28-year-old male patient who was recently diagnosed with non-ST elevated myocardial infarction (NSTEMI) status post-percutaneous coronary intervention (PCI) to left anterior descending (LAD) and type 2 diabetes mellitus (T2DM) and discharged on a new medical regiment that included an SGLT2 inhibitor. The patient presented five days later with dyspnea, nausea, and vomiting. On initial evaluation, he had tachycardia and hypertension. Lab work revealed hyperkalemia, metabolic anion gap acidosis, and the presence of ketones and glucose in the urine, which led to the diagnosis of euglycemic DKA. The patient was started on intravenous (IV) insulin, bicarbonate, and D5 ½ normal saline (NS) and required five days of continuous treatment for the anion gap to close. Considering studies have shown that SGLT2 inhibitors are associated with euglycemic DKA, it is proposed that the use of an SGLT2 inhibitor in this newly diagnosed, post-PCI patient led to the development of euglycemic DKA. DKA most commonly resolves within 24 hours of treatment; however, our patient did not recover until after 120 hours of treatment. Recent studies have suggested that SGLT2-inhibitor euglycemic DKA may be associated with longer recovery time; however, there is still a need to further research the consistency of these findings and quantify the estimated duration of treatment across populations. There is also a need for investigation into how co-morbid factors, such as a recent NSTEMI and PCI, may affect recovery times or predispose patients who are taking SGLT2-inhibitors to develop euglycemic DKA as SGLT2 inhibitors are being more widely prescribed. This case report highlights the importance of creating more detailed and evidence-based guidelines for prescribing SGLT2 inhibitors for patients with diabetes and encourages more research into the expected duration of treatment for patients with SGLT2-induced euglycemic DKA and factors that may affect it.

Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter 2 Inhibitors: Clinical and Biochemical Characteristics of 29 Cases

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.

Delayed diagnosis of severe diabetic ketoacidosis associated with a sodium-glucose cotransporter 2 inhibitor: a case report

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are used to treat patients with type 2 diabetes mellitus but may induce diabetic ketoacidosis (DKA). Owing to their pharmacological mechanisms, they cause a different pathogenesis to that of typical DKA and require special attention in terms of blood glucose concentrations and acidosis. We describe a case of prolonged acidosis because of failure to immediately discover the use of an SGLT2 inhibitor. Compared with typical DKA, SGLT2 inhibitor-associated DKA requires earlier and longer glucose supplementation. SGLT2 inhibitors are specific aetiological factors in DKA, and their use should be suspected when the patient presents with mild hyperglycaemia or prolonged acidosis.

Postcardiac Surgery Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Cotransporter 2 Inhibitors

OBJECTIVES

To evaluate sodium-glucose cotransporter 2 inhibitors (SGLT2i) use and complications (euglycemic diabetic ketoacidosis [eDKA] rate, mortality, infection, hospital, and cardiovascular intensive care unit [CVICU] length of stay [LOS]) in patients undergoing cardiac surgery.

DESIGN

A retrospective study.

SETTING

At an academic university hospital.

PARTICIPANTS

Adult patients undergoing cardiac surgery.

INTERVENTIONS

SGLT2i use versus no SGLT2i use.

MEASUREMENTS AND MAIN RESULTS

The authors evaluated patients undergoing cardiac surgery within 24 hours of hospital admission (between February 2, 2019 to May 26, 2022) for SGLT2i prevalence and eDKA frequency. The outcomes were compared using Wilcoxon rank sum and chi-square testing as appropriate. The cohort included 1,654 patients undergoing cardiac surgery, of whom 53 (3.2%) were prescribed an SGLT2i before surgery; 8 (15.1%) of 53 had eDKA. The authors found no differences between patients with and without SGLT2i use in hospital LOS (median [IQR]: 4.5 [3.5-6.3] v 4.4 [3.4-5.6] days, p = 0.46) or CVICU LOS (median [IQR]: 1.2 [1.0-2.2] v 1.1 [1.0-1.9] days, p = 0.22), 30-day mortality (1.9% v 0.7%, p = 0.31), or sternal infections (0.0% v 0.3%, p = 0.69). Among patients prescribed an SGLT2i, those with and without eDKA had similar hospital LOS (5.1 [4.0-5.8] v 4.4 [3.4-6.3], p = 0.76); however, CVICU LOS was longer in patients with eDKA (2.2 [1.5-2.9] v 1.2 [0.9-2.0], p = 0.042). Mortality (0.0% v 2.2%, p = 0.67) and wound infections (0.0% v 0.0%, p > 0.99) were similarly rare.

CONCLUSIONS

Postoperative eDKA occurred in 15% of patients on an SGLT2i prior to cardiac surgery, and was associated with longer CVICU LOS. Future studies into SGLT2i management perioperatively are important.

Sodium-Glucose Co-Transporter 2 Inhibitors in Heart Failure-Current Evidence in Special Populations

Sodium-glucose co-transporter 2 (SGLT2) inhibitors, originally used for diabetes mellitus, are gaining more popularity for other indications, owing to their positive cardiovascular and renal effects. SGLT2 inhibitors reduce heart failure (HF) hospitalization and improve cardiovascular outcomes in patients with type 2 diabetes. Later, SGLT2 inhibitors were evaluated in patients with HF with reduced ejection fraction (HFREF) and had beneficial effects independent of the presence of diabetes. Recently, reductions in cardiovascular outcomes were also observed in patients with HF with preserved ejection fraction (HFPEF). SGLT2 inhibitors also reduced renal outcomes in patients with chronic kidney disease. Overall, these drugs have an excellent safety profile with a negligible risk of genitourinary tract infections and ketoacidosis. In this review, we discuss the current data on SGLT2 inhibitors in special populations, including patients with acute myocardial infarction, acute HF, right ventricular (RV) failure, left ventricular assist device (LVAD), and type 1 diabetes. We also discuss the potential mechanisms behind the cardiovascular benefits of these medications.

SGLT-2 inhibitors and euglycemic diabetic ketoacidosis/diabetic ketoacidosis in FAERS: a pharmacovigilance assessment

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.

Sodium-glucose cotransporter 2 inhibitor-associated perioperative ketoacidosis: a systematic review of case reports

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.

Life-Threatening Acidosis With Metformin and Dapagliflozin Combination Therapy: A Case Report

Euglycemic keto-acidosis is a known complication of dapagliflozin. However, acidosis can be life-threatening when dapagliflozin is used as a combination therapy with metformin. Our patient was a 64-year-old male, with a history of well-controlled type 2 diabetes mellitus on metformin and dapagliflozin, admitted with vomiting and diarrhea for several days. On presentation, the patient was hypotensive and severely acidotic (pH < 6.7; bicarbonate <5 mmol/L) with an anion gap of 47. Other labs included elevated lactate (19.48 mmol/L), creatinine of 10.39 mg/dL, and elevated beta-hydroxybutyrate levels. The patient was intubated and started on dual vasopressors, insulin drip, and i.v. hydration. Due to worsening acidosis, bicarbonate drip and, subsequently, continuous dialysis was started. The patient's acidosis normalized after two days of dialysis, and he was extubated by day three and discharged by day seven. Dapagliflozin leads to keto-acidosis due to increased hepatic ketogenesis and adipose tissue lipolysis. It also promotes natriuresis, glycosuria, and free water loss. Recurrent vomiting and poor oral intake with concomitant lactic acidosis with metformin can lead to life-threatening acidosis. Clinicians should remain cognizant of the possibility of severe acidosis with the combination therapy of dapagliflozin and metformin in severe dehydration. Adequate hydration may prevent this life-threatening complication.

Sex-dependent effects of canagliflozin and dapagliflozin on hemostasis in normoglycemic and hyperglycemic mice

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are antihyperglycemic drugs that decrease mortality from cardiovascular diseases. However, their effects on hemostasis in the cardioprotective effects have not been evaluated. Therefore, the effects of canagliflozin (CANA, 100 mg/kg, p.o.) and dapagliflozin (DAPA, 10 mg/kg, p.o.) on the parameters of hemostasis were investigated in female and male normoglycemic and streptozotocin (180 mg/kg, i.p.)-induced diabetic mice. CANA and DAPA reduced platelet activity in thrombus in male and female mice both normoglycemic and diabetic. CANA decreased thrombus formation in diabetic male mice, and platelet activation to ADP in diabetic female and male mice. Activation of fibrinolysis was observed in female mice, both normoglycemic and diabetic. DAPA reduced thrombus formation in diabetic male and female mice, and decreased platelet activation to ADP and fibrin formation in diabetic male mice. DAPA increased fibrin formation in normoglycemic female mice and activated fibrinolysis in diabetic female mice. CANA and DAPA exerted sex-specific effects, which were more pronounced in hyperglycemia. The antithrombotic effect of CANA and DAPA was more noticeable in male mice and could be due to platelet inhibition. The effect on coagulation and fibrinolysis was not clear since an increased coagulation and fibrinolysis were observed only in female mice.

A series of diabetic ketoacidosis associated with the use of sodium-glucose co-transporter-2 inhibitors in secondary care

BACKGROUND AND AIMS

Sodium-glucose co-transporter-2 inhibitors (SGLT-2i) are associated with diabetic ketoacidosis (DKA), however limited case series are published.

METHODS

We evaluated the characteristics of patients admitted with SGLT-2i associated DKA.

RESULTS

Over 4 months, 22 patients were identified; 45.5% of DKA was not associated with concurrent illness.

CONCLUSION

DKA is not uncommonly associated with SGLT2i with no clear patient factors associated with severity.

Postop Complication With Euglycemic Diabetic Ketoacidosis in a Patient Receiving Empagliflozin

Euglycemic diabetic ketoacidosis (EDKA) is an uncommon diabetic complication with increasing prevalence and is associated with the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i). We report the case of a 77-year-old female patient with type 2 diabetes mellitus, treated with metformin/linagliptin and empagliflozin, who initiated a slurred speech and altered level of consciousness in the postoperative period of a cholecystectomy. On observation, the patient presented with Kussmaul breathing and mucosal dryness and was ketotic. Laboratory exams showed metabolic acidosis with an elevated anion gap, normoglycemia, and positive ketonemia. Fluid replacement with dextrose solution and continuous insulin infusion were initiated, with progressive clinical and laboratory improvement. On discharge, she showed resolution of symptoms, and empagliflozin was discontinued from her usual medication. Despite the warnings of European and American medical agencies in 2015/2016, EDKA remains a challenging diagnosis due to its unspecific and insidious symptoms.

Right Heart Function in Cardiorenal Syndrome

PURPOSE OF REVIEW

Since CRS is critically dependent on right heart function and involved in interorgan crosstalk, assessment and monitoring of both right heart and kidney function are of utmost importance for clinical outcomes. This systematic review aims to comprehensively report on novel diagnostic and therapeutic paradigms that are gaining importance for the clinical management of the growing heart failure population suffering from CRS.

RECENT FINDINGS

Cardiorenal syndrome (CRS) in patients with heart failure is associated with poor outcome. Although systemic venous congestion and elevated central venous pressure have been recognized as main contributors to CRS, they are often neglected in clinical practice. The delicate hemodynamic balance in CRS is particularly determined by the respective status of the right heart. The consideration of hemodynamic and CRS profiles is advantageous in tailoring treatment for better preservation of renal function. Assessment and monitoring of right heart and renal function by known and emerging tools like renal Doppler ultrasonography or new biomarkers may have direct clinical implications.

A Case of SGLT2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis

While rare, serious adverse effects including euglycemic diabetic ketoacidosis (EDKA) have been associated with sodium-glucose cotransporter-2 inhibitor (SGLT2i) use. We present an interesting case of SGLT2i-induced EDKA occurring two years after initiation of therapy. Most patients with EDKA recover with prompt recognition and treatment. Patient education about identifying early signs remains a cornerstone of early identification and response to SGLT2i-induced EDKA.

Clinical and biochemical characteristics of diabetic ketoacidosis in adults with type 1 or type 2 diabetes at a tertiary hospital in the United Arab Emirates

Background

Diabetes ketoacidosis (DKA) is a well-known acute complication of diabetes. This study aims to describe the sociodemographic, clinical, and biochemical characteristics of adult patients with different diabetes types and DKA severities attending a tertiary hospital in the UAE.

Methods

We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 220 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2020.Results: The average age was 30.6 ± 16.6 years of whom 54.5% were women, 77.7% were UAE nationals and 77.9% were Type 1 diabetes (T1DM). 12.7% were newly diagnosed with diabetes. Treatment noncompliance (31.4%), and infection (26.4%) were the main precipitating factors. Most patients presented with moderate DKA (50.9%). Compared to T1DM, patients with Type 2 diabetes (T2DM) were older (53.6 vs 23.9 years, p < 0.001), had longer hospital stay (12.1 days vs 4.1 days, p < 0.001), had more complications (52.1%, vs 18.9% p <0.001), and a higher mortality rate (6.3% vs 0.6%, p = 0.035). Patients with severe DKA had a shorter diabetes duration compared to mild and moderate DKA (5.7 vs 11.0 vs 11.7 years, respectively, p = 0.007), while complications were significantly lower in the mild group compared to both the moderate and severe groups (11.6% vs 32.1% vs 33.3%, respectively).

Conclusion

The risk of DKA is higher for patients with T1DM than for those with T2DM. The clinical characteristics and outcomes of patients with T2DM differ from those with T1DM highlighting the importance of educating all patients about DKA.

Inpatient perioperative euglycemic DKA due to SGLT2 inhibitors - lessons from a case series and strategies to decrease incidence

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.

The current role of sodium-glucose cotransporter 2 inhibitors in type 2 diabetes mellitus management

Type 2 diabetes mellitus (T2DM) is a chronic, complex metabolic disease characterized by chronic hyperglycemia causing from insufficient insulin signaling because of insulin resistance or defective insulin secretion, and may induce severe complications and premature death. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are oral drugs used to reduce hyperglycemia in patients with T2DM, including empagliflozin, ertugliflozin, dapagliflozin and canagliflozin. The primary objective of this article is to examine the clinical benefit, safety, and tolerability of the four SGLT2 inhibitors approved by the US FDA. SGLT2 inhibitors increase urinary glucose excretion via inhibiting SGLT2 to decrease renal reabsorption of filtered glucose and reduce the renal threshold for glucose. Rather than stimulating insulin release, SGLT2 inhibitors improve β-cell function by improving glucotoxicity, as well as reduce insulin resistance and increase insulin sensitivity. Early clinical trials have confirmed the beneficial effects of SGLT2 in T2DM with acceptable safety and excellent tolerability. In recent years, SGLT2 inhibitors has been successively approved by the FDA to decrease cardiovascular death and decrease the risk of stroke and cardiac attack in T2DM adults who have been diagnosed with cardiovascular disease, treating heart failure (HF) with reduced ejection fraction and HF with preserved ejection fraction, and treat diabetic kidney disease (DKD), decrease the risk of hospitalization for HF in T2DM and DKD patients. SGLT2 inhibitors are expected to be an effective treatment for T2DM patients with non alcoholic fatty liver disease. SGLT2 inhibitors have a similar safety profile to placebo or other active control groups, with major adverse events such as Ketoacidosis or hypotension and genital or urinary tract infections.

The rationale for the need to study sodium-glucose co-transport 2 inhibitor usage in peritoneal dialysis patients

The wave of kidney and heart outcome trials, showing multiple potential benefits for sodium-glucose co-transport 2 (SGLT2) inhibitors, have excluded patients with an estimated glomerular filtration rate below 25 ml/min/1.73 m2. However, dialysis patients are at the highest risk of cardiovascular disease and would benefit most from effective cardioprotective therapies. There is emerging evidence from experimental studies and post hoc analyses of randomised clinical trials that SGLT2 inhibitors are well tolerated and may also be effective in preventing cardiovascular and mortality outcomes in patients with severe chronic kidney disease, including patients receiving dialysis. As such, extending the usage of SGLT2 inhibitors to dialysis patients could provide a major advancement in their care. Peritoneal dialysis (PD) patients have an additional unmet need for effective pharmacotherapy to preserve their residual kidney function (RKF), with its associated mortality benefits, and for treatment options that help reduce the risk of transfer to haemodialysis. Experimental data suggest that SGLT2 inhibitors, via various mechanisms, may preserve RKF and protect the peritoneal membrane. There is sound physiological rationale and an urgent clinical need to execute robust randomised control trials to study the use of SGLT2 inhibitors in PD patients to answer important questions of relevance to patients and healthcare systems.

Characterization, management, and risk factors of hyperglycemia during PI3K or AKT inhibitor treatment

PURPOSE

The phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) pathway controls insulin sensitivity and glucose metabolism. Hyperglycemia is one of the most common on-target adverse effects (AEs) of PI3K/AKT inhibitors. As several PI3K and AKT inhibitors are approved by the United States Food and Drug Administration or are being studied in clinical trials, characterizing this AE and developing a management strategy is essential.

METHODS

Patients with hematologic or solid malignancies treated at Memorial Sloan Kettering Cancer Center with a PI3K or AKT inhibitor were included in this retrospective analysis. A search for patients experiencing hyperglycemia was performed. The frequency, management interventions and outcomes were characterized.

RESULTS

Four hundred and ninety-one patients with 10 unique cancer types who received a PI3K or AKT inhibitor were included. Twelve percent of patients required a dose interruption, 6% of patients required a dose reduction and 2% of patients were hospitalized to manage hyperglycemia. No events occurred among patients receiving β-, γ-, or δ- specific PI3K inhibitor. There was one case where the PI3K or AKT inhibitor was permanently discontinued due to hyperglycemia. Metformin was the most commonly used antidiabetic medication, followed by insulin, sodium-glucose transport protein 2 (SGLT2) inhibitors, and sulfonylurea. SGLT2 inhibitors were associated with the greatest reductions in blood sugar, followed by metformin. At least one case of euglycemic diabetic ketoacidosis (DKA) occurred in a patient on PI3K inhibitor and SGLT2 inhibitor. Body mass index ≥ 25 and HbA1c  ≥ 5.7 are were independently significant predictors of developing hyperglycemia.

CONCLUSION

Hyperglycemia is one of the major on-target side effects of PI3K and AKT inhibitors. It is manageable with antidiabetic medications, treatment interruption and/or dose modification. We summarize pharmacological interventions that may be considered for PI3K/AKT inhibitor induced hyperglycemia. SGLT2-inhibitor may be a particularly effective second-line option after metformin but there is a low risk of euglycemic DKA, which can be deadly. To our knowledge, our report is the largest study of hyperglycemia in patients receiving PI3K/AKT inhibitors.

Sodium-glucose co-transporter 2 inhibitors induced euglycemic diabetic ketoacidosis within four days of initiation

Euglycemic diabetic ketoacidosis (EDKA) is a well-known complication of sodium-glucose co-transporter 2 inhibitors, and many cases with variable onset following the initiation of these agents are reported before, with a median onset of approximately 2 wk. This letter discusses a 45-year-old lady who initially presented with ischemic stroke but developed EDKA 4 d after starting empagliflozin, a rare occurrence. The patient had severe metabolic acidosis that necessitated admission into the intensive care unit. Prompt discontinuation of empagliflozin and DKA management resulted in clinical recovery.

Dapagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient Who Underwent Surgery for Pancreatic Carcinoma: A Case Report

Diabetic ketoacidosis (DKA), an acute and life-threatening complication of diabetes, is a metabolic disorder caused by insulin deficiency and an increase in counter-regulatory hormones. Several cases of DKA without marked hyperglycemia have been reported and are defined as euglycemic DKA (eu-DKA). The use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) is associated with the occurrence of eu-DKA, of which, dapagliflozin is one of the agents. In this study, we report a case of dapagliflozin-associated eu-DKA following surgery for pancreatic carcinoma. A 57-year-old woman presented with acute abdominal pain after surgery for pancreatic carcinoma. Emergency exploratory laparotomy was performed because of suspicion of gastrointestinal perforation based on a CT scan. The surgeons observed that the stomach was significantly dilated but not perforated. Meanwhile, the patient developed shock and severe acidosis. A further examination confirmed the diagnosis of dapagliflozin-associated eu-DKA. We reviewed the precipitating factors and mechanisms of SGLT2i-associated eu-DKA and discussed the treatment and prevention of this condition. Clinicians need to be alert of the occurrence of SGLT2i-associated eu-DKA in patients treated with this drug in the perioperative period.

Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors: A systematic review and quantitative analysis

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Safety and Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitor Combined with Medical Nutrition Therapy for Hyperglycemia in Acute Stroke: A Retrospective Study

Hyperglycemia, a predictor of poor clinical outcomes in acute stroke, must be lowered safely and promptly. We investigated the safety and effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2is) combined with medical nutrition therapy in lowering blood glucose levels. This retrospective study included stroke patients admitted between 2014 and 2019, who (1) had glycated hemoglobin ≥6.5%, blood glucose level ≥ 11.1 mmol/L at admission, (2) took their diet and drugs orally during hospitalization, (3) underwent SGLT2is pharmacotherapy after admission, and (4) underwent a fasting blood glucose (FBG) test on day 7. Patients were provided with a moderate-carbohydrate diet combined with total energy restriction. We assessed the achievement of FBG < 7 mmol/L on day 7 and the need for sulfonylurea or a long-acting insulin analog (LIA) treatment during hospitalization, which carries a risk of hypoglycemia. Fifty-one patients met our inclusion criteria. Of them, 33 (64.7%) achieved the target FBG on day 7. Only eight patients were treated with a small dose of LIA; however, no patients required sulfonylurea. No dehydration occurred. SGLT2is combined with a moderate carbohydrate- and energy-restricted diet achieved the target FBG level safely, effectively, and promptly in mild stroke patients with oral ingestion.

Prolonged ketosis and glycosuria secondary to SGLT2 inhibitor therapy

Clinicians should be aware of the potential for the pharmacologic activity of SGLT2 inhibitors to persist long after the standard drug clearance period of five half-lives, the typical duration used to guide pre-operative medication recommendations.

An Unusual Case of the "Terrible Triad" in a Transgender Woman

With the increasing use of sodium-glucose cotransporter-2 inhibitors for type 2 diabetes and heart failure, clinicians need to understand how to treat euglycemic diabetic ketoacidosis (DKA), which is a potential side effect of the medication. The disease triad of euglycemic ketoacidosis, acute pancreatitis, and hypertriglyceridemia (HTG) has complex pathogenesis, and often the trigger of the triad is unknown. Here, we present an unusual case of euglycemic DKA in a transitioning transgender woman on canagliflozin who was treated with 10% dextrose and insulin infusions and apheresis. What makes our case unique is an added layer of complexity with her use of estrogen supplements contributing to HTG and gallstone formation, which could have set off the disease triad.