Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature

SGLT-2i associated diabetic ketoacidosis in the setting of cardiogenic shock

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus. Sodium-glucose co-transport inhibitors (SGLT-2i), a treatment for type 2 diabetes, have demonstrated a survival benefit in patients with heart failure with reduced ejection fraction (HFrEF). Many patients with HFrEF have been started on SGLT-2i and sometimes transitioned off insulin due to improved glycaemic control. SGLT-2i have demonstrated an association with DKA. Here, we present a case of simultaneous cardiogenic shock and DKA in the setting of recent transition from insulin to an SGLT-2i. DKA in conjunction with decompensated heart failure is a combination that will likely occur more frequently as SGLT-2i use becomes more widespread in patients with HFrEF, and its identification and management require special considerations. Volume status, potassium management and recognition of DKA in these patients must be approached differently than in other cases of DKA.

Sodium-Glucose Cotransporter 2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis: The Other Side of the Coin!

Euglycemic diabetic ketoacidosis (EDKA) though rare is a life-threatening complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors. With their increasing use in the management of type 2 diabetes mellitus (T2DM) due to long-term beneficial effects, the incidence of this complication is on the rise. We report a case of a 58-year-old lady with a history of T2DM on multiple anti-diabetes medications including dapagliflozin for one year, who during intercurrent illness developed EDKA. Her blood sugar on admission was 203 mg/dL, and arterial blood gas showed high anion-gap metabolic acidosis (HAGMA) with ketonuria and ketonemia (blood beta-hydroxybutyric (BOHB) acid level: 5.4 mmol/L). Low carbohydrate intake, dehydration resulting from repeated vomiting, and skipping the previous two days' dose of insulin could have precipitated this condition. She was treated with intravenous fluids, insulin, 5% dextrose infusion, and potassium supplements with complete resolution of acidosis after about 90 hours. This case signifies the importance of awareness of the link between the use of SGLT2 inhibitors and EDKA and early recognition of this complication to reduce morbidity and mortality. Furthermore, it also emphasizes the need for clinicians to educate their patients taking these drugs to stop them during the intercurrent illness to prevent them from developing EDKA.

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.

"Normal but Catastrophic" Euglycemic Diabetic Ketoacidosis Precipitated by Sodium-Glucose Cotransporter-2 Inhibitor Use: A Case Report

Euglycemic diabetic ketoacidosis (EuDKA) is an uncommon diabetic complication. Just like diabetic ketoacidosis (DKA), EuDKA is a medical emergency. EuDKA is primarily related to the imbalance between insulin and counter-regulatory hormones, with an elevated insulin/glucagon ratio, and is characterized by blood glucose near normal (blood glucose less than 250 mg/dL) in the background of DKA. There are many factors associated with EuDKA, but the overall mechanism is based on a relative state of carbohydrate deficit, resulting in ketosis while maintaining near-normal glucose levels. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new oral antidiabetic medication category that can precipitate EuDKA. EuDKA is more common in patients with diabetes mellitus on SGLT2 inhibitors with lower mass index and decreased glycogen store which can be triggered by surgery, infection, trauma, a major illness or reduced food intake and persistent vomiting, gastroparesis, dehydration, and reduced insulin dosages. This is a case of a 34-year-old male, Filipino, diagnosed with type 2 diabetes mellitus, who was maintained on dapagliflozin + metformin 5mg/1000mg taken twice a day with good compliance and was admitted with EuDKA precipitated by decreased food intake and managed with intravenous insulin. Throughout admission, the blood glucose levels did not exceed 250mg/dL. His clinical condition improved through insulin therapy, administration of sodium bicarbonate, and intravenous hydration. EuDKA is an uncommon diabetic complication. High clinical suspicion is required to avoid delay in diagnosis and management since normal blood sugar levels masquerade the underlying DKA. Nevertheless, the cornerstone for the management of DKA and EuDKA remains the same: intravenous hydration and insulin therapy.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis

Introduction

Euglycemic diabetic ketoacidosis (DKA) (glucose <250 milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period.

Methods

This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18 years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18 millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250 milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250 mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05.

Results

We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561 mg/dL, P < 0.001) and potassium (4.3 vs 5.3 mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18 mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70 mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3 mmol/L) was 27.3 vs 19.1% (P = 0.23).

Conclusion

Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Preoperative considerations for patients with diabetes

INTRODUCTION

Patients undergoing surgery require a thorough assessment preoperatively. Hyperglycemia is associated with poor outcomes, and stability of glucose levels is an important factor in preoperative management. Diabetes presents a particular challenge since patients are often on multiple medications encompassing glycemic management and cardiovascular therapies.

AREAS COVERED

A PubMed search of published data and reviews on preoperative approaches in diabetes was conducted. Consensus opinion drives most of the guidelines and recommendations for management of diabetes in surgical patients. Pathophysiology is often complex with varying levels of glucose and surgical stress. Establishing well-controlled diabetes prior to surgical intervention should be standard practice in non-emergent procedures. We review the best practices for implementing preoperative assessment, with diabetes with a focus on diabetes medications.

EXPERT OPINION

The management of a patient preoperatively varies by region and country. Institutions differ in approaches to preoperative evaluation and the establishment of consistent approaches would provide a platform for monitoring patient outcomes. Multidisciplinary teams and pre-assessment clinics for preoperative evaluation can enhance patient care for those undergoing surgery.

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.

Euglycemic diabetic ketoacidosis (EDKA) after pancreaticoduodenectomy: An under-recognized metabolic abnormality with outcome implications

BACKGROUND

Euglycemic diabetic ketoacidosis is a metabolic condition characterized by relative euglycemia, ketonemia, and metabolic acidosis that occurs through mechanisms resembling starvation. Pancreaticoduodenectomy is a complex abdominal operation that subjects patients to a prolonged fasting and an inflammatory state. This study examined the incidence of euglycemic diabetic ketoacidosis and potential opportunities for early diagnosis and management in patients undergoing pancreaticoduodenectomy.

METHODS

A single-institution retrospective review of 350 patients who underwent pancreaticoduodenectomy between 2017 and 2020 was performed. Primary endpoints were peak beta-hydroxybutyrate levels, peak lactate levels, lowest pH, peak base deficits, and urinary output within the first 24 hours, postoperatively. Additional endpoints included incidence of postoperative pancreatic fistula, delayed gastric emptying, total complications, postoperative hospital length of stay, readmission rates, and changes in insulin regimen at discharge.

RESULTS

Of the 350 cases reviewed, 39 (11.1%) patients developed euglycemic diabetic ketoacidosis. Male sex and pancreatic cancer were associated with a risk for euglycemic diabetic ketoacidosis (P < .05). Patients with euglycemic diabetic ketoacidosis had significantly higher peak beta-hydroxybutyrate levels than patients without euglycemic diabetic ketoacidosis (mean difference = 19.8 mg/dL, 95% confidence interval = 14.7-24.9, P < .001), and were nearly four times more likely to require insulin at discharge (odds ratio 3.8, 95% confidence interval = 1.1-13.0, P < .05).

CONCLUSION

This is the first large descriptive study that investigates euglycemic diabetic ketoacidosis after pancreaticoduodenectomy. Euglycemic diabetic ketoacidosis after pancreaticoduodenectomy is associated with significantly higher beta-hydroxybutyrate levels and new or increased insulin requirement at discharge. Our study demonstrates potential markers for euglycemic diabetic ketoacidosis after pancreaticoduodenectomy, offering an opportunity to identify and successfully treat this disease in a timely manner.

Sodium-Glucose Cotransporter-2 Inhibitor-associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery

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.

Empagliflozin induced euglycemic diabetic ketoacidosis. A case reports

Introduction

Diabetic ketoacidosis (DKA) is one of the most serious acute complications of diabetes. Its defining features are hyperglycemia and ketoacidosis. Euglycemic DKA (EDKA) affects patients whose serum glucose levels are within the normal range. The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors is one of the newly identified risks for this condition.

Case presentation

A 75-year-old woman with type 2 diabetes mellitus presented to our emergency department with decreased consciousness and decreased oral intake for two days. She had been diagnosed with a cerebrovascular accident for 12 days, and empagliflozin was added to her medications. Laboratory evaluation revealed metabolic acidosis, despite a minimally elevated serum glucose concentration. The patient was admitted to the intensive care unit with EDKA secondary to empagliflozin and treated with intravenous rehydration therapy and intravenous insulin infusion.

Conclusions

Empagliflozin (SGLT2 inhibitor) is a new anti-hyperglycemic medication that is associated with an increased risk of DKA. Several patients present with normal or minimally elevated serum glucose concentration, which frequently leads to a delay in diagnosis. EDKA should be considered when evaluating a patient with unexplained metabolic acidosis while taking an SGLT2 inhibitor, and SGLT2 inhibitors should be discontinued if acidosis is confirmed.

SGLT-2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis: A Case Report and a Literature Review

Diabetic ketoacidosis (DKA) is considered a medical emergency, most commonly associated with type 1 diabetes mellitus, and is relatively rare in type 2 diabetes mellitus (T2DM). We discuss a case of a 45-year-old woman with T2DM who presented to the emergency room with worsening lethargy and weakness. Before her presentation, her physician had recently added empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, to her anti-diabetic drug regimen along with glimepiride and a combination drug of vildagliptin and metformin. Based on the clinical examination and lab findings, DKA was suspected, but her glucose level was below the cutoff value for DKA diagnosis. However, her lab results showed significant metabolic acidosis and ketonemia with no clinical or laboratory features of sepsis. Therefore, the diagnosis of euglycemic diabetic ketoacidosis (eu-DKA) was made. She was successfully treated according to the DKA protocol and discharged in good condition. In this report, our aim is to discuss the relationship between SGLT-2 inhibitors with eu-DKA. Given the absence of significant hyperglycemia, recognition of this entity by clinicians may be delayed. Serum ketones should be obtained in diabetic patients with symptoms of nausea, vomiting, or malaise while taking SGLT-2 inhibitors, and SGLT-2 inhibitors should be discontinued if ketoacidosis is confirmed.

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.

An Unsuspected Case of Euglycemic Diabetic Ketoacidosis With Twists

Euglycemic diabetic ketoacidosis (EDKA) is defined by acidosis, ketones in serum and urine, and a high anion gap (AG) with a normal glucose level. Sodium-glucose cotransporter-2 (SGLT2) inhibitor has become one of the most common causes of EDKA. We present one of the lowest presenting blood glucose levels for the EDKA in the setting of SGLT2 inhibitor use. A 34-year-old female with a two-year history of type 2 diabetes mellitus (T2DM) presented after accidental ingestion of a metal clip and lack of oral intake for 28 hours. She reported a recent intentional weight loss of 60 lbs. She takes metformin 1000 mg twice daily and empagliflozin 25 mg daily. An urgent endoscopy was planned in the intensive care unit given the proximal location of the foreign body. The basic metabolic profile after the procedure demonstrated a glucose level of 75 mg/dL, bicarbonate level of 11 mmol/L, and AG of 17 mmol/L. The venous pH was 7.27 with a partial pressure of carbon dioxide of 30 mmHg. The urinalysis showed a glucose level greater than 500 μmol/L with a ketone level of 80 μmol/L. The blood and urine toxicology screening results were unremarkable. The patient was treated for EDKA with the administration of intravenous (IV) dextrose 5% in water with subsequent initiation of IV insulin. The assessment of her insulin reserve revealed a low C-peptide of 0.36 ng/mL, a high glutamic acid decarboxylase level greater than 250 IU/mL, and high zinc transporter 8 (ZnT8) antibodies of 42 U/mL, consistent with an undiagnosed transition to latent autoimmune diabetes in adults (LADA). The blood glucose levels for previously reported cases remain between 90 and 250 mg/dL. In this case, the combination of a low carbohydrate diet and prolonged starvation may have led to the impressively low glucose. Additionally, the SGLT2 inhibitor use in patients with LADA serves as one of the known risk factors for EDKA. EDKA poses a diagnostic challenge, especially in the ICU setting where there exists a myriad of causes for high AG metabolic acidosis. Additionally, many of the ICU patients are in a ketotic state brought on by prolonged starvation. Therefore, prompt diagnosis and treatment for EDKA require careful history taking and complete investigation for other causes of high AG metabolic acidosis.

SGLT-2 inhibitors for treatment of heart failure in patients with and without type 2 diabetes: A practical approach for routine clinical practice

Sodium-glucose cotransporter-2 inhibitors (SGLT-2i), initially studied and approved for the treatment of diabetes, are now becoming a promising class of agents to treat heart failure (HF) and chronic kidney disease (CKD), even in patients without diabetes. While the potential benefits in several diseases (usually treated by different medical specialties) is amplifying the interest in these drugs, their use in frail patients with multiple pathologies and on polypharmacy can be complex, requiring a composite multidisciplinary approach. Following a brief overview of the evidence supporting the benefits of SGLT-2i in patients with HF or CKD, we herein provide guidance for prescribing SGLT-2i in daily practice using a multidisciplinary approach. A shared treatment algorithm is presented for initiating an SGLT-2i in patients already being treated for diabetes and HF. Tools to prevent hypoglycemia, blood pressure drop, genital infections, euglycemic diabetic ketoacidosis and eGFR dip are also provided. It is hoped that this practical, multidisciplinary guidance for initiating SGLT-2i in patients with HF and/or CKD, whatever therapy they are currently on, can help to offer SGLT-2i to the largest population of patients possible to provide the most therapeutic benefit.

“The Bitter Truth of Sugar”—Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series

Diabetic ketoacidosis (DKA) is an acute and major complication of diabetes mellitus (DM), both type I and type II. Biochemically, DKA consists of a triad of blood sugar levels greater than 250 mg/dL, ketonemia of greater than 3 mmol/L and/or significant ketonuria, and a blood pH less than 7.3 with an increased anion gap. Currently, the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are widely used in management of type II diabetes. There have been several reports of an association between euglycemic diabetic ketoacidosis (EuDKA) and SGLT-2i agents. We present three different patients who were on SGLT-2i therapy who developed recurrent EuDKA postprocedure or sepsis. We believe that prolonged treatment (5–6 days) with intravenous (IV) insulin with glucose until resolution of glycosuria can be considered as an inexpensive marker of resolution of EuDKA. Moreover, the recommended duration for discontinuation of these drugs prior to elective procedures should be longer than 3 days.

How to cite this article: Shah M, Pathrose E, Bhagwat NM, Chandy D. “The Bitter Truth of Sugar”—Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series. Indian J Crit Care Med 2022;26(1):123–126.

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

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Case Report: High-Calorie Glucose Infusion and Tight Glycemic Control in Ameliorating Refractory Acidosis of Empagliflozin-Induced Euglycemic Diabetic Ketoacidosis

The current widespread use of sodium-glucose co-transporter 2 (SGLT2) inhibitors has triggered an increase in reported cases of euglycemic diabetic ketoacidosis (EDKA), often characterized by a protracted metabolic acidosis that is resistant to conventional DKA treatment. We report a case of empagliflozin-induced EDKA with severe metabolic acidosis intractable to aggressive fluid resuscitation and boluses of bicarbonate infusion. Following the introduction of high-calorie glucose infusion coupled with tight glycemic control, the recalcitrant acidosis was successfully corrected. This is the first case report that adopts the above approach, representing a paradigm shift in the management of SGLT2 inhibitor-induced EDKA.

Normoglycemic diabetic ketoacidosis in a type 2 diabetes patient on dapagliflozin: A case report

A 48-year-old male patient with Type 2 diabetes mellitus(T2D), on insulin replacement therapy, glipizide, and dapagliflozin presented with generalized weakness with weight loss of 40 pounds in 6 months ever since he was started on dapagliflozin. He was hemodynamically stable on arrival with a finger stick glucose of 121 gm%. Physical examination was unremarkable except for dry mucus membranes. His laboratory results on arrival are shown in Table 1. His serum osmolar gap was within the normal range. He was treated insulin drip per DKA protocol and gap was closed, the patient was clinically and biochemically back to baseline, and he was discharged home. Delayed diagnosis of normoglycemic diabetic ketoacidosis (DKA) in adults with diabetes treated with multiple antidiabetic drugs (eg, sodium-glucose cotransporter-2 [SGLT-2] inhibitors) can potentially increase morbidity and mortality. Patient education in terms of symptoms and signs, physician awareness of early recognition of ketoacidosis in the setting of paradoxically normal or near-normal blood glucose levels in these patients is the primary focus of this case study. This is paradoxical DKA because theoretically patient is not meeting one of the criteria for DKA which include triad of hyperglycemia, Ketoacidosis with widened anion gap, Ketonemia. This is a short case report of presumed SGLT-2 inhibitor euglycemic diabetic ketoacidosis. The main teaching point is recognition and early diagnosis of this issue when multiple diabetic medications are present with the absence of hyperglycemia. This is, by current definition, not DKA because theoretically, the patient does not meet one of the criteria for DKA as the patient was apparently not hyperglycemic, albeit with, ketoacidosis and widened anion gap. (ketonemia).

Euglycemic Diabetic Ketoacidosis in a Sedated Patient after Coronary Artery Bypass Grafting: A Case Report and Literature Review

Euglycemic diabetic ketoacidosis (EDKA) is a rare and serious adverse effect of sodium-glucose cotransporter 2 inhibitors (SGLT-2i). The diagnosis is challenging due to the rarity, nonspecific symptoms, and absence of the alarmingly high blood glucose levels, and thus, it could be initially missed resulting in delayed treatment. This is particularly important for sedated patients, as the absence of typical clinical signs and symptoms can obscure the diagnosis. We present the case of a patient with type 2 diabetes mellitus on empagliflozin who developed EDKA while sedated after coronary artery bypass grafting (CABG) despite stopping the medication 24 hours prior to surgery. We also summarize the current literature on EDKA after CABG. Physicians must be aware and maintain a high index of suspicion for the illness, especially in patients with T2DM taking SGLT-2i and undergoing a major operation such as CABG. Emergent treatment and multidisciplinary follow-up are needed to improve patient outcomes and mitigate complications. Physicians should also consider identifying the optimal time to discontinue SGLT-2i before major surgeries and possible ketone studies in such patients, especially those sedated following the surgery.

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.

Sodium-Glucose Co-transporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Bariatric Surgery: A Case and Literature Review

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce cardiovascular, kidney, and overall mortality. SGLT2i are also associated with a rare adverse event, euglycemic diabetic ketoacidosis (EDKA). This report describes a case of EDKA one day after bariatric surgery in a 51-year-old female with type 2 diabetes mellitus managed with the SGLT2i, canagliflozin. She was following a ketogenic diet for three weeks prior to surgery. The patient made a steady recovery with rapid anion gap closure followed by prolonged non-anion gap metabolic acidosis. Her medical record was tagged with a life-threatening reaction to SGLT2i. The risk of EDKA from SGLT2i may be increased by a low carbohydrate diet or postoperative status. Our case was complicated by hypokalemia, exemplifying the need for aggressive electrolyte management. Further guidance is needed to manage risk factors provoking EDKA and the use of SGLT2i therapy after an episode of EDKA.

Euglycemic Ketoacidosis as a Complication of SGLT2 Inhibitor Therapy

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are drugs designed to lower plasma glucose concentration by inhibiting Na+-glucose-coupled transport in the proximal tubule. Clinical trials demonstrate these drugs have favorable effects on cardiovascular outcomes to include slowing the progression of CKD. Although most patients tolerate these drugs, a potential complication is development of ketoacidosis, often with a normal or only a minimally elevated plasma glucose concentration. Inhibition of sodium-glucose cotransporter-2 in the proximal tubule alters kidney ATP turnover so that filtered ketoacids are preferentially excreted as Na+ or K+ salts, leading to indirect loss of bicarbonate from the body and systemic acidosis under conditions of increased ketogenesis. Risk factors include reductions in insulin dose, increased insulin demand, metabolic stress, low carbohydrate intake, women, and latent autoimmune diabetes of adulthood. The lack of hyperglycemia and nonspecific symptoms of ketoacidosis can lead to delays in diagnosis. Treatment strategies and various precautions are discussed that can decrease the likelihood of this complication.

Sodium glucose-linked transport protein 2 inhibitors: An overview of genitourinary and perioperative implications

Sodium glucose-linked transport protein 2 inhibitors are relatively novel drugs, used for the treatment of type 2 diabetes mellitus. Their use since Pharmaceutical Benefits Scheme approval in Australia has increased drastically, possibly due to the low risk of hypoglycemic events and their advertised cardiovascular mortality benefits. However, as with any novel drug, adverse effects regarding their use require medical practitioner awareness for optimal patient outcomes. This paper aims to cover the major urological implications, including those pertinent perioperatively, that concern this class of drugs. There is a clear risk of developing genital mycotic infections with the use of sodium glucose-linked transport protein 2 inhibitors, including serious infections such as Fournier's gangrene. Evidence for developing urinary tract infections has been mixed. Sodium glucose-linked transport protein 2 inhibitor-induced lower urinary tract symptoms may have impacts on quality of life via pollakiuria and nocturia, of which there are increased reports. Perioperative use increases the risk of euglycemic diabetic ketoacidosis. It is recommended that sodium glucose-linked transport protein 2 inhibitors be ceased perioperatively.

Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Euglycemic diabetic ketoacidosis (eu-DKA) is an uncommon and serious adverse event associated with the use of sodium-glucose cotransporter (SGLT-2) inhibitors. It is a state of increased anion gap metabolic acidosis with ketosis but in the setting of normal serum glucose levels. Diagnosis of this serious entity could easily be missed given the non-specific symptoms and the normal glucose measurements. This ketogenic state can be triggered by various stressors including infection, surgery, myocardial infarctions, omission of insulin dosage, as well as low carbohydrate diet. In this report, we present a case of eu-DKA in a 68-year-old woman with type 2 diabetes that occurred in the postoperative period of glaucoma surgery. She was started shortly before surgery on SGLT-2 inhibitor (ertugliflozin). While the diagnosis was initially missed, it was subsequently confirmed when she presented with reduced appetite, generalized fatigue, and constipation. Ertugliflozin was discontinued, and she was successfully treated with conservative management and without insulin drip. This case highlights the need to consider the diagnosis of eu-DKA in patients treated with SGLT-2 inhibitors since the diagnosis could easily be missed especially in the postoperative period with the non-characteristic symptomatology and normoglycemia.

Diabetic ketoacidosis in patients treated with SGLT2 inhibitors: experience at a tertiary hospital

PURPOSE

Diabetic ketoacidosis (DKA) is a rare and life-threatening complication in patients with diabetes. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) have rarely been associated with ketoacidosis. The aim of this retrospective study was to investigate DKA episodes occurring after SGLT2i treatment and to compare them to DKA episodes due to other causes.

METHODS

The medical records of the years 2018-2020 related to clinical and biochemical characteristics and to treatment of six patients with DKA due to SGLT2i were reviewed. They were compared to those of 12 patients with DKA due to other causes.

RESULTS

On admission, the most common symptom was abdominal pain. Glucose levels (median, min-max) were lower in patients with SGLT2i-induced DKA compared to those with DKA due to other causes (229 (150-481) vs. 458.5 (332-695) mg/dl, p = 0.007), whereas no statistical difference was observed in HbA1c and in the severity of DKA (pH, HCO₃, CO₂, and anion gap). The duration of insulin infusion (41 (33-124) vs. 21.50 (11-32) h, p < 0.001) and the time required until DKA resolution (39 (31-120) vs. 19 (9-28) h, p < 0.001) were higher in patients with SGLT2i-induced DKA than those with DKA due to other causes. In addition, there were increased fluid requirements (14 (8-22.75) vs. 5.5 (2-24) L, p = 0.013) and longer hospitalization time (11 (6-22) vs. 5.5 (2-14) days, p = 0.024) in patients with SGLT2i-induced DKA. No statistically significant differences were observed in total intravenous insulin and potassium administration until DKA resolution.

CONCLUSIONS

Patients with SGLT2i-induced DKA had lower serum glucose levels on admission and required increased fluid administration and longer time to recover from acidosis compared to patients with DKA from other causes.

Diabetic Euglycemic Ketoacidosis Induced by Oral Antidiabetics Type SGLT2i

Euglycemic diabetic ketoacidosis (euglycemic DKA) is a serious complication of diabetes, which can occur in some patients treated with oral antidiabetics called sodium-glucose co-transporter 2 inhibitors (SGLT2i). This group of drugs works by increasing renal excretion of sodium and glucose, thereby lowering blood glucose levels. Euglycemic DKA is characterized by having blood glucose levels in the normal range, usually below 200 mg/dL (11 mmol/L), which complicates early diagnosis. We present the case of a 67-year-old patient with type 2 diabetes mellitus, treated with metformin and empagliflozin, who was admitted to the Intensive Care Unit in a coma with severe ketoacidotic decompensation.

Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management

INTRODUCTION

Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL.

OBJECTIVE

This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians.

DISCUSSION

EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology.

CONCLUSIONS

Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.

Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA

Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.

[Confusion, tachypnea, and tachycardia in a 71-year-old man with type 2 diabetes mellitus]

Bei Patienten mit Diabetes mellitus Typ 2 muss im Falle einer unklaren Bewusstseinsstörung und/oder Bauchschmerzen eine Natrium/Glukose-Kotransporter-2(SGLT-2)-Inhibitor-induzierte diabetische Ketoazidose in die Differenzialdiagnose einbezogen werden. Dabei können die Blutzuckerspiegel trotz ausgeprägter Azidose nur moderat erhöht sein. Bei Nachweis ist eine umgehende intensivmedizinische Therapie unerlässlich.

Penetration rates of new pharmaceutical products in Europe: A comparative study of several classes recently launched in type-2 diabetes

BACKGROUND

Different countries have their own systems for evaluating new medicines, and they make decisions as to when and how each new medicine is adopted.

PURPOSE

To compare the rate of uptake of new diabetes medicines (dipeptidyl peptidase-4 inhibitors [DPP-4Is], glucagon-like peptide-1 receptor agonists [GLP1-RAs], and sodium-glucose co-transporter-2 inhibitors [SGLT2Is]) in the five most populated European countries.

METHODS

The monthly volume of sales of antidiabetic drugs was extracted for each country from the IQVIA™ MIDAS® database for the period 2007 to 2016 and the defined daily doses (DDDs) were calculated. For each new drug, market shares were expressed as a percentage of the total market of non-insulin antidiabetic agents.

RESULTS

Sharp differences were observed between the countries. Overall, the highest and fastest rates of uptake were seen for Germany and Spain, compared to lower rates for the UK and Italy. This was especially marked for DPP-4Is, where the market share reached over 30% of non-insulin antidiabetic drugs in Germany and Spain, compared to around 10% in the UK and Italy. In France, there was an initial rapid uptake, which stabilized at around 20% after three years. Rates of uptake were lower for the other drugs, with the GLP1-RAs reaching a market share of 2.5-4.5% in Germany, Spain and France, compared to less than 2.5% in the UK and Italy. The SGLT2Is reached a market share of 5-8% in Spain and Germany, compared to less than 4% in the UK and Italy, and they were not launched at all in France in March 2020.

CONCLUSION

The differences in the uptake of new antidiabetic drugs may reflect different methods for assessing and introducing new medicines, as well as cultural factors. The uptake of the new medicines would appear to be more cautious in the UK and Italy, perhaps due to concerns about cost-effectiveness, whereas in Germany and Spain, and possibly also France, a new medicine's potential benefits may be prioritized.

A Case of SGLT2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis Following Coronary Artery Bypass Surgery

Objective

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel group of oral hypoglycemic agents with multiple proven beneficial effects. However, their use has been associated with euglycemic diabetic ketoacidosis (DKA), typically triggered by risk factors such as acute illness, surgery, and decreased calorie intake. Therefore, it is recommended that patients discontinue SGLT2 inhibitors at least 24 hours before surgery to minimize this risk. We report a case of a postoperative euglycemic DKA in a patient who had discontinued SGLT2 inhibitor therapy 48 hours prior to surgery.

Methods

We describe the clinical course of a patient with type 2 diabetes mellitus on empagliflozin therapy who was referred for coronary artery bypass graft surgery.

Results

A 60-year-old man with type 2 diabetes mellitus developed euglycemic DKA a few hours after coronary artery bypass graft surgery. Laboratory results showed acute postoperative elevated anion gap metabolic acidosis with normal glucose and elevated blood ketone levels. It was later revealed that the patient was treated as an outpatient with empagliflozin; the last dose was taken 48 hours prior to his procedure.

Conclusion

Euglycemic DKA can occur postoperatively in patients with a history of SGLT2 inhibitor use, even 48 hours after the discontinuation of therapy. This case highlights the need to revisit the recommended time to discontinue these agents, specifically prior to major surgery, because their pharmacokinetic effects may persist after 24 hours of discontinuation, putting patients at risk for postoperative euglycemic DKA.

[Metabolic acidosis of surprising origin in a 61-year-old female patient]

A 61-year-old female patient presented to the emergency room with nausea. Laboratory findings revealed metabolic acidosis, which had to be associated with a sodium-glucose co-transporter‑2 (SGLT2) inhibitor. Due to increasing prescription rates of SGLT2 inhibitors for diabetes mellitus, congestive heart failure or chronic renal insufficiency, a growing numbers of cases of SGLT2 inhibitor-associated ketoacidosis should be expected. Calculating the anion gap can provide orientation in the case of acidosis of unknown origin. Presumably, a relevant proportion of such cases of ketoacidosis is currently being overlooked or its diagnosis delayed.

Prolonged euglycemic diabetic ketoacidosis triggered by a single dose of sodium-glucose cotransporter 2 inhibitor

A 45-year-old woman was admitted for diabetic ketoacidosis (DKA). Aggressive rehydration and continuous intravenous insulin resulted in improved blood glucose levels; however, metabolic acidosis persisted. One day prior to admission, the patient took a single dose of a sodium-glucose cotransporter 2 (SGLT2) inhibitor and this likely contributed to the prolonged euglycemic DKA. A single dose of this drug remained effective for over 100 hours as evidenced by massive excretion of urine glucose continuing long after blood glucose normalisation. SGLT2 inhibitor use should be refrained in cases in which DKA has already occurred as they may result in increasing severity or prolonged DKA.

Euglycemic Diabetic Ketoacidosis Precipitated by a Keto Diet: Importance of Dietary History in Diagnosis

Diabetic ketoacidosis (DKA) is one of the serious complications of diabetes, especially type 1. It is defined by the triad of hyperglycemia (>250 mg/dL [>13.9 mmol/L]), high anion-gap metabolic acidosis, and increased plasma ketones. Euglycemic ketoacidosis is characterized by DKA without hyperglycemia. We present a rare case of a 28-year-old type 1 diabetic male, presenting with abdominal pain, fatigue, and dizziness after one week of starting a keto diet. He was diagnosed with euglycemic DKA, managed with DKA protocol and given detailed dietary counselling to avoid the keto diet in future.

Prevalence and Clinical Characteristics of Adults Presenting With Sodium-Glucose Cotransporter-2 Inhibitor-Associated Diabetic Ketoacidosis at a Canadian Academic Tertiary Care Hospital

OBJECTIVES

In this study, we examined the prevalence and clinical characteristics of sodium-glucose cotransporter-2 inhibitor (SGLT2i)-associated diabetes ketoacidosis (DKA).

METHODS

A retrospective chart review of patients admitted for DKA over 4 years. Patients with SGLT2i-associated DKA were invited for pancreatic autoantibody testing. A subset of patients were invited for an interview to identify clinical characteristics suggestive of undiagnosed latent autoimmune diabetes in adults (LADA).

RESULTS

Of 647 DKA admissions, 6.6% were associated with SGLT2i use. Time from SGLT2i initiation and DKA ranged from 2 weeks to 3.25 years; 69.8% had euglycemic DKA. Pancreatic autoantibody testing on 20 patients identified 5 originally diagnosed with type 2 as having LADA. Four were interviewed and had a LADA clinical risk score predictive of this diagnosis.

CONCLUSIONS

A larger study is needed to qualify the role of the LADA clinical risk score with confirmatory pancreatic autoantibody testing before SGLT2i initiation to reduce DKA risk.

Sodium-Glucose Cotransporter-2 Inhibitors in Nephrology Practice: A Narrative Review

Purpose of the review:

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are recommended for eligible patients with type 2 diabetes for the secondary prevention of adverse cardiovascular and kidney disease outcomes. Patients with type 2 diabetes and albuminuric chronic kidney disease, a history of atherosclerotic cardiovascular disease, and/or heart failure with reduced ejection fraction should be assessed for the use of these therapies.

Sources of information:

The sources include published clinical trials with SGLT2is, with a focus on cardiovascular safety studies and kidney protection trials.

Methods:

Information was gathered via a review of relevant literature and clinical practice guidelines, incorporated with real-life clinical experience.

Key findings:

Clinicians prescribing these agents must be familiar with the benefits of SGLT2is on cardiovascular and renal endpoints, and with adverse effects of SGLT2is, including mycotic genital infections and diabetic ketoacidosis. Primary care physicians and specialists should know how to adjust antihypertensive, antiglycemic, and diuretic agents. With the results of completed cardiovascular outcome trials and the Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy trial, nephrologists specifically have a unique opportunity to impact the safe, effective, and equitable implementation of SGLT2is into clinical practice.

Limitations:

Further work is needed in specific patient subgroups, including patients with chronic kidney disease stages IV and V, patients with kidney disease but lower levels of albuminuria, and in patients without diabetes.

Euglycaemic diabetic ketoacidosis in a 43-year-old woman with type 2 diabetes mellitus on SGLT-2 inhibitor (empagliflozin)

We report a case of euglycaemic diabetic ketoacidosis (EDKA) in a 43-year-old woman with type 2 diabetes mellitus who presented to the emergency department with problems of vomiting, cough, shortness of breath and generalised weakness after following a ketogenic diet for 2 weeks. Therapy with sodium glucose transport protein-2 empagliflozin had been started 2 months prior. Initial evaluation revealed high anion gap metabolic acidosis with blood glucose level of 169 mg/dL. Treatment for EDKA with fluid resuscitation, intravenous insulin and dextrose resolved her acidosis and symptoms in less than 24 hours. Empaglifozin was discontinued on discharge. This entity represents a diagnostic challenge since the differential diagnosis is broad with a potentially misleading clinical presentation that can result in delayed diagnosis and adverse outcomes including acute kidney injury, multiple electrolyte abnormalities, cerebral oedema, acute respiratory distress syndrome, shock and death.