1
|
Frontino G, Di Tonno R, Castorani V, Rigamonti A, Morotti E, Sandullo F, Scialabba F, Arrigoni F, Foglino R, Dionisi B, Ferri CIC, Zirpoli S, Barera G, Meschi F, Bonfanti R. Non-Occlusive Mesenteric Ischemia in Children With Diabetic Ketoacidosis: Case Report and Review of Literature. Front Endocrinol (Lausanne) 2022; 13:900325. [PMID: 35928892 PMCID: PMC9345499 DOI: 10.3389/fendo.2022.900325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite the use of technology, recurrent diabetic ketoacidosis (DKA) prevention remains an unmet need in children and adolescents with T1D and may be accompanied by life-threatening acute complications. We present a rare case of non-occlusive mesenteric ischemia (NOMI) with overt manifestation after DKA resolution and a discussion of recent literature addressing DKA-associated NOMI epidemiology and pathogenesis in children and adolescents. CASE PRESENTATION A 13-year-old female with previously diagnosed T1D, was admitted at our emergency department with hypovolemic shock, DKA, hyperosmolar state and acute kidney injury (AKI). Mildly progressive abdominal pain persisted after DKA correction and after repeated ultrasound evaluations ultimately suspect for intestinal perforation, an intraoperative diagnosis of NOMI was made. CONCLUSION The diagnosis of DKA-associated NOMI must be suspected in pediatric patients with DKA, persistent abdominal pain, and severe dehydration even after DKA resolution.
Collapse
Affiliation(s)
- Giulio Frontino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Raffaella Di Tonno
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Valeria Castorani
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- *Correspondence: Valeria Castorani,
| | - Andrea Rigamonti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Elisa Morotti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Federica Sandullo
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesco Scialabba
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Arrigoni
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Foglino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benedetta Dionisi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Salvatore Zirpoli
- Pediatric Radiology and Neuroradiology, Children’s Hospital “V. Buzzi”, Milan, Italy
| | - Graziano Barera
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Franco Meschi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Bonfanti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
2
|
Takiguchi T, Arai M, Kim S, Ishii H, Ogasawara T, Shigeta K, Mizobuchi T, Yokobori S. Nonocclusive mesenteric ischemia associated with a hyperosmolar hyperglycemic state: Hepatic portal venous gas as an indicator of mesenteric ischemia. Acute Med Surg 2021; 8:e673. [PMID: 34221411 PMCID: PMC8243755 DOI: 10.1002/ams2.673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background The diagnosis of nonocclusive mesenteric ischemia (NOMI) is always challenging in critically ill patients. Herein, we aimed to report a case of NOMI associated with a hyperosmolar hyperglycemic state (HHS). A small amount of hepatic portal venous gas (HPVG) triggered the diagnosis of NOMI. Case Presentation A 77‐year‐old man was transferred due to shock and disorder of consciousness. He was diagnosed with an HHS. We suspected intestinal ischemia due to a small amount of HPVG revealed by computed tomography (CT). Peritoneal signs were revealed after treatment for the HHS. Computed tomography was carried out again 5 h after admission, which showed a large amount of HPVG, remarkable bowel dilatation, and pneumatosis intestinalis. We performed an emergency laparotomy and resected the small bowel necrosis resulting from NOMI. Conclusion An HHS can cause NOMI, and the presence of HPVG on CT is an important finding that suggests mesenteric ischemia, even in small amounts.
Collapse
Affiliation(s)
- Toru Takiguchi
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Masatoku Arai
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Shiei Kim
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Hiromoto Ishii
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Tomoko Ogasawara
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Kenta Shigeta
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Taiki Mizobuchi
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| |
Collapse
|
3
|
Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf 2020; 42:1449-1469. [PMID: 31372935 DOI: 10.1007/s40264-019-00854-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment. METHODS A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission. RESULTS We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L. CONCLUSIONS Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.
Collapse
Affiliation(s)
- Isabelle H S Kuan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Ruth L Savage
- New Zealand Pharmacovigilance Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
| |
Collapse
|
4
|
Stahl K, Rittgerodt N, Busch M, Maschke SK, Schneider A, Manns MP, Fuge J, Meyer BC, Hoeper MM, Hinrichs JB, David S. Nonocclusive Mesenteric Ischemia and Interventional Local Vasodilatory Therapy: A Meta-Analysis and Systematic Review of the Literature. J Intensive Care Med 2019; 35:128-139. [DOI: 10.1177/0885066619879884] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background:Intensive care patients with nonocclusive mesenteric ischemia (NOMI) show mortality rates of 70% to 90%. Besides emergency surgery, different interventional local vasodilatory treatment (LVT) attempts have been described. We performed a systematic review and a meta-analysis to evaluate feasibility, efficacy, and tolerability of LVT in patients with life-threatening NOMI.Methods:Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed until February 2019. Measured outcomes included immediate technical success rates (as indicated by mesenteric vasodilation on angiography or clinical improvement) and adverse events (AEs). Therapeutic efficacy was measured by the assessment of overall mortality.Results:Twelve studies (335 patients, 245 received LVT) from 1977 to 2018 were included. All studies were retrospective (4 comparative and 8 noncomparative). Different intra-arterial vasodilators (4× papaverine, 6× prostaglandin E1, 1× tolazoline/heparin, 1× tolazoline + iloprost) were reported. Initial technical success rate was 75.9% (95% confidence interval [CI], 55.1%-89%, P = .017) with an AE rate of 2.9% (95% CI: 1.3%-6.6%; P = .983). Overall mortality in LVT patients was 40.3% (95% CI: 28.7%-53%, P = .134). In 4 studies, outcomes were compared between patients receiving LVT to those who received standard of care (odds ratio for death in LVT patients was 0.261 [95% CI: 0.095-0.712, P = .009]).Conclusions:Local vasodilatory treatment appears to be safe in patients with NOMI and might have the potential to at least partially reverse mesenteric vasoconstriction features in control angiographies. However, with no randomized and prospective studies available yet, the overall quality of published studies has to be considered as low; therefore, it is not possible to draw generalizable conclusions from the present data concerning clinical end points. Its application might hold promise as a rescue treatment strategy and deserves further evaluation in randomized controlled trials.
Collapse
Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Nina Rittgerodt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sabine K. Maschke
- Department of Diagnostic und Interventional Radiology, German Centre of Lung Research (DZL), Hannover, Germany
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Bernhard C. Meyer
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Marius M. Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Department of Diagnostic und Interventional Radiology, German Centre of Lung Research (DZL), Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| |
Collapse
|
5
|
Smith ZR, Horng M, Rech MA. Medication‐Induced Hyperlactatemia and Lactic Acidosis: A Systematic Review of the Literature. Pharmacotherapy 2019; 39:946-963. [DOI: 10.1002/phar.2316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Zachary R. Smith
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan
| | - Michelle Horng
- Department of Pharmacy Services The University of Texas MD Anderson Cancer Center Houston Texas
| | - Megan A. Rech
- Department of Pharmacy Loyola University Medical Center Maywood Illinois
- Department of Emergency Medicine Stritch School of Medicine Loyola University Chicago Chicago Illinois
| |
Collapse
|
6
|
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
|
7
|
Stahl K, Busch M, Maschke SK, Schneider A, Manns MP, Fuge J, Wiesner O, Meyer BC, Hoeper MM, Hinrichs JB, David S. A Retrospective Analysis of Nonocclusive Mesenteric Ischemia in Medical and Surgical ICU Patients: Clinical Data on Demography, Clinical Signs, and Survival. J Intensive Care Med 2019; 35:1162-1172. [PMID: 30909787 PMCID: PMC7536530 DOI: 10.1177/0885066619837911] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: To analyze demography, clinical signs, and survival of intensive care
patients diagnosed with nonocclusive mesenteric ischemia (NOMI) and to
evaluate the effect of a local intra-arterial prostaglandin therapy. Methods: Retrospective observational study screening 455 intensive care patients with
acute arterial mesenteric perfusion disorder in a tertiary care hospital
within the past 8 years. Lastly, 32 patients with NOMI were enrolled, of
which 11 received local intra-arterial prostaglandin therapy. The diagnosis
of NOMI was based on the clinical presentation and established biphasic
computed tomography criteria. Clinical and biochemical data were obtained 24
hours before, at the time, and 24 hours after diagnosis. Results: Patients were 60.5 (49.3-73) years old and had multiple comorbidities. Most
of them were diagnosed with septic shock requiring high doses of
norepinephrine (NE: 0.382 [0.249-0.627] μg/kg/min). The Sequential Organ
Failure Assessment (SOFA) score was 18 (16-20). A decrease in oxygenation
(Pao2/Fio2), pH, and bicarbonate and an increase in international
normalized ratio, lactate, bilirubin, leucocyte count, and NE dose were
early indicators of NOMI. Median SOFA score significantly increased in the
last 24 hours before diagnosis of NOMI (16 vs 18, P <
.0001). Overall, 28-day mortality was 75% (81% nonintervention vs 64%
intervention cohort; P = .579). Median SOFA scores 24 hours
after intervention increased by +5% in the nonintervention group and
decreased by 5.5% in the intervention group (P =
.0059). Conclusions: Our data suggest that NOMI is a detrimental disease associated with
progressive organ failure and a high mortality. Local intra-arterial
prostaglandin application might hold promise as a rescue treatment strategy.
These data encourage future randomized controlled trials are desirable.
Collapse
Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Sabine K Maschke
- Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover, Germany.,* Jan B. Hinrichs and Sascha David have contributed equally to this work
| | - Sascha David
- Department of Nephrology and Hypertension, 9177Hannover Medical School, Hannover, Germany.,* Jan B. Hinrichs and Sascha David have contributed equally to this work
| |
Collapse
|
8
|
Itoh Y, Sagawa R, Kinoshita H, Tamba S, Yamamoto K, Yamada Y, Matsuzawa Y. Small-intestinal necrosis due to non-occlusive mesenteric ischemia with diabetic ketoacidosis after quetiapine treatment. Diabetol Int 2018; 10:225-230. [PMID: 31275790 DOI: 10.1007/s13340-018-0386-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/23/2018] [Indexed: 11/26/2022]
Abstract
We report a 66-year-old male who developed diabetic ketoacidosis (DKA) and necrosis of the small intestine due to non-occlusive mesenteric ischemia (NOMI), 3 months after starting quetiapine treatment. He was transferred to our hospital and diagnosed as diabetic for the first time, associated with DKA. Despite improvement in DKA, abdominal pain worsened gradually 10 h after hospitalization. Computed tomography (CT) revealed bowel emphysema, and gas out of the gut wall, in the mesenteric veins and the intrahepatic portal vein, suggesting intestinal necrosis. He survived because of resection of necrotic small-intestinal tissue and he finally required no diabetes treatment. Mesenteric arteries were patent with good palpitation without occlusion or thrombosis, and pathological findings showed ischemic enteritis, which is consistent with NOMI. DKA is a rare but serious side effect of second-generation antipsychotic medications (SGAMs) such as quetiapine, which can result in NOMI: a life-threatening complication. We must keep in mind that the plasma glucose concentration may increase in patients taking SGAMs, or that NOMI may occur concurrently if DKA develops.
Collapse
Affiliation(s)
- Yoshito Itoh
- 1Departments of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005 Japan
| | - Ryo Sagawa
- 2General Medicine, Sumitomo Hospital, Osaka, Japan
| | | | - Sachiko Tamba
- 1Departments of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005 Japan
| | - Koji Yamamoto
- 1Departments of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005 Japan
- 2General Medicine, Sumitomo Hospital, Osaka, Japan
| | - Yuya Yamada
- 1Departments of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005 Japan
| | - Yuji Matsuzawa
- 1Departments of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005 Japan
| |
Collapse
|
9
|
Milder DA, Milder TY, Kam PCA. Sodium-glucose co-transporter type-2 inhibitors: pharmacology and peri-operative considerations. Anaesthesia 2018. [DOI: 10.1111/anae.14251] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- D. A. Milder
- Concord Repatriation Hospital, Hospital Road; Concord NSW Australia
| | - T. Y. Milder
- St. Vincent's Hospital; Darlinghurst NSW Australia
| | - P. C. A. Kam
- University of Sydney; Royal Prince Alfred Hospital; Camperdown NSW Australia
| |
Collapse
|
10
|
Bonora BM, Avogaro A, Fadini GP. Sodium-glucose co-transporter-2 inhibitors and diabetic ketoacidosis: An updated review of the literature. Diabetes Obes Metab 2018; 20:25-33. [PMID: 28517913 DOI: 10.1111/dom.13012] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/12/2017] [Accepted: 05/13/2017] [Indexed: 12/15/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are increasingly used for the treatment of type 2 diabetes (T2D) and can improve glucose control also in type 1 diabetes (T1D). In May 2015, regulatory agencies issued a warning that SGLT2is may cause diabetic ketoacidosis (DKA). We report details on 2 new cases of SGLT2i-associated DKA and review the literature for similar cases within randomized controlled trials (RCTs), cohort studies and single reports. We searched the medical literature for reports of SGLT2i-associated DKA cases. A quantitative analysis of frequency and clinical characteristics is reported. The 2 narrative cases illustrate that SGLT2i-associated DKA can occur in patients with T1D incorrectly diagnosed as T2D, perhaps without the presence of obvious DKA precipitating factors. The incidence of SGLT2i-associated DKA was less than 1/1000 in randomized controlled trials and 1.6/1000 person-years in cohort studies. We retrieved detailed data on 105 SGLT2i-associated DKA case reports, wherein 35% showed glucose levels of less than 200 mg/dL and 22% were not associated with typical triggers. In case reports and in pharmacovigilance databases, duration of SGLT2i treatment before DKA onset was extremely variable. Fatal SGLT2i-associated DKA episodes were found only in pharmacovigilance databases and represented 1.6% of all reported cases. DKA is a rare adverse event during SGLT2i therapy. Predisposing and precipitating factors are still incompletely understood, although a minority of cases lacked typical DKA triggers. More narrative case series and cohort studies are needed to better understand the true risk and the spectrum of this adverse event.
Collapse
Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
| | | |
Collapse
|
11
|
SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis. Clin Ther 2017; 38:2654-2664.e1. [PMID: 28003053 DOI: 10.1016/j.clinthera.2016.11.002] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/02/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA. METHODS Reports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel. FINDINGS DKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended. IMPLICATIONS Preventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.
Collapse
|