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Chaudhry A, Roels C, Lee J. Sodium-Glucose Cotransporter-2 Inhibitor-associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery. Can J Diabetes 2022; 46:843-850. [PMID: 36068154 DOI: 10.1016/j.jcjd.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/06/2022] [Accepted: 06/15/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). This risk is further pronounced in the perioperative period. There is no consensus for when SGLT2i should be held preoperatively, and recommendations from various organizations have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association guidelines. Further study of patients with perioperative euglycemic DKA is required to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents. METHODS In this retrospective, single-centre case series we examined 4 patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent semiurgent surgery. We characterized their clinical course, predisposing factors and treatment characteristics. RESULTS The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24 hours after surgery. The fourth patient developed euglycemic DKA on postoperative day 3 in the context of significant hypovolemia and exhibited potential signs of protracted SGLT2i action at 7 days since the last dose. CONCLUSIONS The duration of SGLT2i action and risk for DKA is variable and complex. Providers should hold SGLT2i at least 3 days before elective major surgery, with potentially longer times in high-risk patients. Careful vigilance should be used for perioperative DKA development in all patients recently exposed to SGLT2i.
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Affiliation(s)
- Ahsen Chaudhry
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada.
| | - Craig Roels
- Lower Mainland Pharmacy Services, Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Julie Lee
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada
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Murugesan KB, Balakrishnan S, Arul A, Ramalingam S, Srinivasan M. A retrospective analysis of the incidence, outcome and factors associated with the occurrence of euglycemic ketoacidosis in diabetic patients on sodium glucose co-transporter - 2 inhibitors undergoing cardiac surgery. Ann Card Anaesth 2022; 25:460-465. [PMID: 36254911 PMCID: PMC9732953 DOI: 10.4103/aca.aca_47_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/31/2021] [Accepted: 08/08/2021] [Indexed: 11/07/2022] Open
Abstract
Introduction SGLT2i is a new class of drugs used for type 2 diabetes. SGLT2i are known to cause EuKA in the perioperative period. Euglycemic ketoacidosis (EuKA) can cause life-threatening metabolic acidosis in the perioperative setting. Though the event rate of SGLT2i associated diabetic ketoacidosis in nonoperative setting is low, incidence among peri-operative patients can be very high and remains unknown. Aim The aim of this study was to find the incidence, analyze outcome, and establish correlation between risk factors and EuKA in cardiac surgical patients on SGLT2i. Materials and Methods This is a retrospective study analyzing 24 cardiac surgical patients who were on SGLT2i for type 2 diabetes mellitus. Data collection included age, sex, BMI, preoperative HbA1C, albumin, creatinine, type of SGLT2i and timing of stopping before surgery, insulin administration in the immediate pre-operative period; use of CPB, GI infusion and inotropes in the intraoperative period; blood ketone, duration of ventilation, hydration status and length of postoperative stay in postoperative period. Patients were diagnosed to have EuKA if any one of the serially measured postoperative ketone values was more than 0.6 mmol/L (ketone positive). The collected data were used to find an association between the risk factors and the occurrence of EuKA. Results Of the 24 patients, 17 patients developed EuKA. (70.8.%). 10 of the 17 EuKA in our study required preoperative Insulin for diabetic control whereas none in the ketone negative patients required insulin. This was statistically significant (P = 0.019). Association of other factors to EuKA were not statistically significant. Conclusion Though the event rate of SGLT2i associated Diabetic ketoacidosis in nonoperative setting is low, (17), the occurrence of EUKA in cardiac surgical patients on SGLT2i in our study was 70.8% (17 out of 24 patients). Patients who require insulin in addition to other oral hypoglycemic drugs for immediate preoperative glycemic control are at risk for the development of SGLT2 inhibitor-induced EuKA postoperatively. Missing the diagnosis of EuKA is fatal in these patients. We couldn't make a diagnosis in our first patient whom we lost. Since it was diagnosed in all our study patients by measuring serial ketone values, there was no mortality and insignificant morbidity. Cessation of SGLT2i before surgery, expectant watch for blood ketones, and treatment with GI infusion reduce morbidity and mortality in cardiac surgical patients.
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Affiliation(s)
- Karthik Babu Murugesan
- Department of Cardiac Anaesthesia, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Soundravalli Balakrishnan
- Department of Cardiac Anaesthesia, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Anandhi Arul
- Department of Cardiac Anaesthesia, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Srinivasan Ramalingam
- Department of Endocrinology, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Muralidharan Srinivasan
- Department of Cardiothoracic Surgery, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
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Abioye RO, Okagu IU, Udenigwe CC. Targeting Glucose Transport Proteins for Diabetes Management: Regulatory Roles of Food-Derived Compounds. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2022; 70:5284-5290. [PMID: 35439410 DOI: 10.1021/acs.jafc.2c00817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
With the rapid rise in prevalence, diabetes mellitus is one of the leading causes of mortality worldwide. Impaired cellular glucose transport is a major contributor to diabetes progression and, thus, an important target for treatment. Functional foods are a rich source of antidiabetic agents. These compounds target multiple physiological contributors to diabetes with lower risk for side effects. This perspective highlights recent advances in food-derived compounds that regulate the gene expression or activity of glucose transport proteins (SGLT1, SGLT2, GLUT1, GLUT2, and GLUT4) and provides insights for future research on targeting the transporters as a promising antidiabetic mechanism of nutraceutical compounds.
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Affiliation(s)
- Raliat O Abioye
- Department of Chemistry and Biomolecular Sciences, Faculty of Science, University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
| | - Innocent U Okagu
- Department of Biochemistry, Faculty of Biological Sciences, University of Nigeria, Nsukka 410001, Nigeria
| | - Chibuike C Udenigwe
- Department of Chemistry and Biomolecular Sciences, Faculty of Science, University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
- School of Nutrition Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario K1H 8M5, Canada
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Wang R, Kave B, McIlroy E, Kyi M, Colman PG, Fourlanos S. Metabolic outcomes in patients with diabetes mellitus administered SGLT2 inhibitors immediately before emergency or elective surgery: single centre experience and recommendations. Br J Anaesth 2021; 127:e5-e7. [PMID: 33934891 DOI: 10.1016/j.bja.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/06/2021] [Accepted: 03/10/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ray Wang
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia.
| | - Benjamin Kave
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia
| | - Edward McIlroy
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Australia
| | - Mervyn Kyi
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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Himes CP, Ganesh R, Wight EC, Simha V, Liebow M. Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clin Proc 2020; 95:2760-2774. [PMID: 33168157 DOI: 10.1016/j.mayocp.2020.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
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Affiliation(s)
- Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Zaidi SO, Khan Y, Razak BS, Malik BH. Insight Into the Perioperative Management of Type 2 Diabetes. Cureus 2020; 12:e6878. [PMID: 32190441 PMCID: PMC7058399 DOI: 10.7759/cureus.6878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/04/2020] [Indexed: 01/14/2023] Open
Abstract
Diabetic people are at risk of developing acute complications when exposed to stress. Surgery brings a stressful period when the patient is exposed not only to surgical stress but also the effects of medications used during that particular period. The patient's comorbidities can influence the perioperative management of diabetes. Poorly controlled diabetes can complicate the hospital course. The literature was searched through PubMed and the articles of the last 5 years, from 2014 to 2019, were looked into. The studies available as a free text, in the English language and related to humans, were included. Inclusion criteria also included adults with type 2 diabetes undergoing surgery. The perioperative management of diabetes is a challenging one. Apart from the diabetes control; comorbidities, general health, intake, and interaction of medications both anti-diabetic and non-diabetic, type and duration of surgery, are some of the factors that influence the outcome of the surgery. With a variety of options available to manage diabetes currently, it is important to have a good insight into their effects to prevent complications to occur and ensure safe discharge from the hospital. The good control of diabetes is essential in bringing favorable outcomes. The perioperative management of diabetes should be individualized. Oral anti-hyperglycemic medications, other than sulfonylureas and SGLT2 inhibitors, provide a reasonable alternative to insulin and can be continued safely perioperatively depending upon the type of surgery and the patient is expected to resume oral intake soon postoperatively.
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Affiliation(s)
- Syed Owais Zaidi
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Yusra Khan
- Pharmacy, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bibi S Razak
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Thiruvenkatarajan V, Nanjappa N, Sembu M, Meyer EJ, Van Wijk RM, Jesudason D. An analysis of the Australian Therapeutic Goods Administration Database of Adverse Event Notifications of diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitors in surgical patients. Anaesth Intensive Care 2020; 48:70-72. [PMID: 31955586 DOI: 10.1177/0310057x19892988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Venkatesan Thiruvenkatarajan
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Nagesh Nanjappa
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Manesha Sembu
- University of New South Wales, Kensington, Australia
| | - Emily J Meyer
- Department of Endocrinology and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.,Department of Endocrinology and Diabetes, Queen Elizabeth Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Roelof M Van Wijk
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - David Jesudason
- Department of Endocrinology and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.,Department of Endocrinology and Diabetes, Queen Elizabeth Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, Australia
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Thiruvenkatarajan V, Meyer EJ, Nanjappa N, Van Wijk RM, Jesudason D. Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review. Br J Anaesth 2019; 123:27-36. [DOI: 10.1016/j.bja.2019.03.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/17/2019] [Accepted: 03/17/2019] [Indexed: 12/29/2022] Open
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Kuzulugil D, Papeix G, Luu J, Kerridge RK. Recent advances in diabetes treatments and their perioperative implications. Curr Opin Anaesthesiol 2019; 32:398-404. [PMID: 30958402 PMCID: PMC6522201 DOI: 10.1097/aco.0000000000000735] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed. RECENT FINDINGS The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes. SUMMARY Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.
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Affiliation(s)
| | - Gabrielle Papeix
- Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital
| | - Judy Luu
- Department of Endocrinology, John Hunter Hospital
- Department of General Medicine, John Hunter Hospital
- Diabetes Stream, Hunter New England Local Health District
- School of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ross K. Kerridge
- Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital
- School of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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