A Case of Euglycemic Diabetic Ketoacidosis due to Canagliflozin Complicated by Takotsubo Cardiomyopathy

Sodium-glucose co-transporter-2 (SGLT2) inhibitors, integral in type 2 diabetes mellitus (T2DM) management, are not without risks, with reported adverse effects including euglycemic diabetic ketoacidosis (EDKA). We present a case of a 75-year-old female with T2DM on canagliflozin, who developed altered mental status (AMS), nausea, vomiting, and hypotension. The laboratory results revealed ketoacidosis, elevated troponins, and Takotsubo cardiomyopathy (TC), prompting the cessation of canagliflozin. This paradoxical EDKA case underscores the necessity for cautious prescribing. Additionally, our discussion delves into the risk factors, mechanisms, and epidemiology of EDKA associated with SGLT2 inhibitors (SGLT2i), emphasizing the importance of individualized medicine and shared decision-making in their use, despite their proven cardiovascular benefits.

Section: Discussionmentioning

confidence: 99%

“…Since CPT-I facilitates the transport of fatty acids into mitochondria for beta-oxidation, reduced insulin levels stimulate CPT-I activity, further promoting ketone body production. Additionally, the administration of SGLT2 inhibitors may stimulate glucagon secretion, further promoting ketogenesis [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Beyond the Benefits: A Case Study on the Complications of Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors (Euglycemic Diabetic Ketoacidosis (DKA) and Takotsubo Cardiomyopathy)

Sabanci,

Saaed,

Bandi

et al. 2024

“…The first case of DKA-induced TC reported in the literature was in 2009 by Nanda et al [ 17 ]. Since then, more cases of TC induced by DKA were reported [ 17 - 19 ]. However, Katayama et al reported the first case of TC induced by both DKA and hypothermia [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

A Case of Takotsubo Cardiomyopathy Triggered by Diabetic Ketoacidosis and Hypothermia

Mhanna

Beran

Srour

et al. 2020

Takotsubo cardiomyopathy (TC), also recognized as stress-induced cardiomyopathy, is a transient condition of left ventricular (LV) dysfunction, which presents similarly to acute coronary syndrome (ACS) but with normal coronaries. Physical or emotional stressors usually precipitate TC. It is typically a benign condition, with a complete resolution once the triggering cause resolves. There have been a few cases of TC induced by diabetic ketoacidosis (DKA) that have been reported in the literature. A 50-year-old Caucasian female patient presented with lethargy, in addition to hypothermia and hypotension. Further investigation showed hyperglycemia with metabolic acidosis and ketonemia. Eventually, she was diagnosed with diabetic ketoacidosis (DKA). On Day 2 of the admission, the patient’s condition further deteriorated despite appropriate treatment of DKA. An electrocardiogram (EKG) showed ST-segment elevation in inferior leads, and troponin levels were elevated. Cardiac catheterization showed non-obstructive coronary arteries but a severely reduced cardiac index. Echocardiography showed an ejection fraction (EF) of 25% with global hypokinetic LV. Eventually, the patient was diagnosed with TC or stress-induced cardiomyopathy. TC should always be suspected in any patient presenting with acute heart failure during DKA treatment. TC is a transient syndrome; however, it can result in dreadful complications, including cardiogenic shock, arrhythmias, or thromboembolic events. Early recognition and timely treatment are pivotal in such cases.

Takotsubo Cardiomyopathy Complicating Diabetic Ketoacidosis, Hypothermia and Hypernatremia in a Comatose Patient

AlShehabi,

Hallak,

Battistin

et al. 2024

Takotsubo cardiomyopathy (TCM) is a transient wall motion abnormality of the left ventricular apex associated with emotional or physical stress. In the setting of diabetic ketoacidosis (DKA), it is thought to be caused by the compound effect of a catecholamine surge and the noxious effect of acidosis and ketones leading to myocardial stunning. In this report, the first of its kind in the Middle East, we describe the case of a 71-year-old comatose patient, who was being treated for DKA and hypernatremia and was incidentally diagnosed with TCM. We also review 15 case reports of DKA-induced TCM published to date in the literature, many of which had an atypical presentation and good outcomes. Furthermore, we discuss possible risk factors for TCM in our case and supporting literature. It is recommended to maintain increased vigilance and attempt early identification of such conditions in acutely ill patients to prevent life-threatening complications.