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

A Case of Severe Metabolic Acidosis in the Setting of a Strict Ketogenic Diet

Patients with metabolic acidosis often present with obscure, multifactorial etiologies, making efficient diagnosis and treatment key to preventing poor clinical outcomes. This case report describes a patient with severe metabolic acidosis in which the underlying cause was not immediately apparent. After a thorough work-up and history taking, the patient's strict ketogenic diet was identified as the most likely source of his illness. Over multiple days, the patient improved as he resumed a normal diet and was treated for refeeding syndrome. This case highlights the importance of taking a comprehensive social and diet history when assessing a patient with metabolic acidosis. It also highlights the need for physicians to understand and be ready to counsel on the possible effects of fad diets, such as the ketogenic diet.

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

Although the recommended preoperative cessation period for sodium-glucose cotransporter 2 inhibitors (SGLT2is) changed in 2020 (from 24 h to 3-4 days preoperatively) to reduce the risk of SGLT2i-associated perioperative ketoacidosis (SAPKA), the validity of the new recommendation has not been verified. Using case reports, we assessed the new recommendation effectiveness and extrapolated precipitating factors for SAPKA. We searched electronic databases up to June 1, 2022 to assess SAPKA (blood pH < 7.3 and blood or urine ketone positivity within 30 days postoperatively in patients taking SGLT2i). We included 76 publications with 99 cases. The preoperative SGLT2i cessation duration was reported for 59 patients (59.6%). In all cases with available cessation periods, the SGLT2is were interrupted < 3 days preoperatively. No SAPKA cases with > 2-day preoperative cessation periods were found. Many case reports lack important information for estimating precipitating factors, including preoperative SGLT2i cessation period, body mass index, baseline hemoglobin A1c level, details of perioperative fluid management, and type of anesthesia. Our study suggested that preoperative SGLT2i cessation for at least 3 days could prevent SAPKA. Large prospective epidemiologic studies are needed to identify risk factors for SAPKA.

Detection of Euglycemic Diabetic Ketoacidosis During Thoracic Surgery 75 Hours After Empagliflozin Discontinuation

Euglycemic diabetic ketoacidosis (eDKA) has been increasingly reported as an adverse event of sodium-glucose cotransporter 2 inhibitors (SGLT2i), and the accompanying information on the drug recommends discontinuation three days prior to scheduled surgery. We present a case of a 50-year-old woman who developed eDKA during surgery for a metastatic lung tumor 75 hours after discontinuing SGLT2i. In this case, the onset of eDKA was detected using intraoperative blood gas analysis and urinary ketone measurements. Hence, perioperative eDKA can occur even after three or more days of SGLT2i withdrawal.

New Diabetic Medication Sodium-Glucose Cotransporter-2 Inhibitors Can Induce Euglycemic Ketoacidosis and Mimic Surgical Diseases: A Case Report and Review of Literature

Background

Euglycemic diabetic ketoacidosis (EDKA) is a potentially life-threatening condition and a reported side effect of antidiabetic sodium-glucose-cotransporter-2-inhibitors (SGLT2-I). The analysis of the herein presented case and its management formed the incentive to prepare this multidisciplinary work and includes an overview about perioperative SGLT2-I-induced ketoacidosis.

Method

A PubMed search on relevant entries was conducted combining the terms “euglycemic diabetic ketoacidosis” AND “surgery.”

Results

A total of 33 articles on SGLT2-I-induced ketoacidosis in the context of surgical treatment were identified. According to this literature research risk factors for the development are infection, perioperative fasting, surgical stress, and insulin dose reduction.

Conclusion

Unspecific symptoms mimicking acute abdomen and normoglycemia can lead to delayed diagnosis of EDKA and might harm patients under SGLT2-I therapy in the perioperative setting. SGLT2-I medication should be withheld for at least 24–48 h prior to surgery according to this review of literature and restarted only in stable clinical conditions to avoid the severe complication of EDKA.

Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

Background

Sodium glucose cotransporter-2 (SGLT2) inhibitors have been proven to be very effective in the management of type II diabetes. These medications can cause adverse drug reactions such as genital mycotic infections. Another critical adverse drug reaction is euglycemic diabetic ketoacidosis (EDKA) under the setting of other contributing risk factors for developing diabetic ketoacidosis. Case Presentation. We report a case of a 45-year-old gentleman with type 2 diabetes mellitus on empagliflozin, metformin, and glimepiride who presented with abdominal pain, fatigue, and vomiting. Of note, he started a ketogenic diet three days before his presentation and self-stopped his antidiabetic medications two days before his presentation. The patient was found to have euglycemic diabetic ketoacidosis and was treated as per the protocol. He was discharged on metformin and pioglitazone. Two weeks following discharge, canagliflozin was added.

Conclusion

Euglycemic diabetic ketoacidosis could still be precipitated despite discontinuation of SGLT2I under a ketogenic diet. Discussion related to the initiation of a ketogenic diet should occur between the care provider and the patient.

Diabetes and Cancer: Risk, Challenges, Management and Outcomes

BACKGROUND

Diabetes mellitus and cancer are commonly coexisting illnesses, and the global incidence and prevalence of both are rising. Cancer patients with diabetes face unique challenges. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in cancer patients.

METHODS

A literature search using keywords in PubMed was performed. Studies that were published in English prior to July 2021 were assessed and an overview of epidemiology, cancer risk, outcomes, treatment-related hyperglycemia and management of diabetes in cancer patients is provided.

RESULTS

Overall, 8-18% of cancer patients have diabetes as a comorbid medical condition. Diabetes is a risk factor for certain solid malignancies, such as pancreatic, liver, colon, breast, and endometrial cancer. Several novel targeted compounds and immunotherapies can cause hyperglycemia. Nevertheless, most patients undergoing cancer therapy can be managed with an appropriate glucose lowering agent without the need for discontinuation of cancer treatment. Evidence suggests that cancer patients with diabetes have higher cancer-related mortality; therefore, a multidisciplinary approach is important in the management of patients with diabetes and cancer for a better outcome.

CONCLUSIONS

Future studies are required to better understand the underlying mechanism between the risk of cancer and diabetes. Furthermore, high-quality prospective studies evaluating management of diabetes in cancer patients using innovative tools are needed. A patient-centered approach is important in cancer patients with diabetes to avoid adverse outcomes.