Euglycaemic diabetic ketoacidosis in a patient with type 2 diabetes started on empagliflozin

Abstract

SUMMARYDiabetes ketoacidosis (DKA) is largely associated with type 1 diabetes and has hyperglycaemia as a cardinal feature. We discuss the case of a 42-year-old man, a patient with type 2 diabetes, who presented to the emergency room, with nausea, vomiting and abdominal pain. He had recently changed his diabetes medications and started on an SGLT2 inhibitor (empagliflozin) along with metformin, pioglitazone, liraglutide and self-adjusted exogenous insulin. DKA was suspected in the wake of clinical examination and lab findings but glucose levels were below the cut-off for DKA; therefore, he was diagnosed with euglycaemic DKA. He was successfully managed with intravenous hydration and insulin infusion. We discuss the link of SGLT2 inhibitors with DKA and the pathophysiology behind euglycaemic DKA. BACKGROUND

Sodium‐glucose co‐transporter‐2 inhibitors and diabetic ketoacidosis: An updated review of the literature

“…We retrieved a total of 105 episodes of DKA in patients receiving SGLT2i from May 2014 to April 2017 . Demographic characteristics, type of diabetes and type of SGLT2i are reported in Table .…”

Impact of Sodium-Glucose Cotransporter 2 Inhibitors on Nonglycemic Outcomes in Patients with Type 2 Diabetes

“…Postmarketing reports of serious cases of diabetic ketoacidosis (DKA) resulting in emergency department visits or hospitalization have been recorded for a small number of patients treated with SGLT2 inhibitors; most patients had T2D but some cases of DKA in patients with T1D were also reported, implying off‐label use . Some of these cases of DKA have occurred in patients without significant hyperglycemia and were therefore diagnosed as “euglycemic diabetic ketoacidosis.” Published case reports have also documented episodes of DKA in patients receiving SGLT2 inhibitors in patients with T1D (i.e., off‐label use) and T2D . These reports indicate that the occurrence of DKA is rare and is possibly triggered by factors such as acute febrile illness, reduced calorie intake, reduced insulin dose, and causes of pancreatic insufficiency .…”

“…47 Some of these cases of DKA have occurred in patients without significant hyperglycemia and were therefore diagnosed as "euglycemic diabetic ketoacidosis." [47][48][49][50] Published case reports have also documented episodes of DKA in patients receiving SGLT2 inhibitors in patients with T1D 48 (i.e., off-label use) and T2D. 48,[50][51][52] These reports indicate that the occurrence of DKA is rare and is possibly triggered by factors such as acute febrile illness, reduced calorie intake, reduced insulin dose, and causes of pancreatic insufficiency.…”

“…[47][48][49][50] Published case reports have also documented episodes of DKA in patients receiving SGLT2 inhibitors in patients with T1D 48 (i.e., off-label use) and T2D. 48,[50][51][52] These reports indicate that the occurrence of DKA is rare and is possibly triggered by factors such as acute febrile illness, reduced calorie intake, reduced insulin dose, and causes of pancreatic insufficiency. 46 The FDA issued a warning to alert patients and health care professionals to be aware of signs and symptoms of DKA, regardless of ambient plasma glucose levels, and the U.S. product labeling for dapagliflozin, canagliflozin, and empagliflozin was subsequently updated (December 2015).…”

“…In patients with T1D and those with T2D, the association between improved glycemic control and the reduced risk of microvascular complications is well established. The efficacy of canagliflozin, dapagliflozin, and empagliflozin in lowering elevated blood glucose concentrations is well documented . However, the positive effect observed with these SGLT2 inhibitors on nonglycemic factors, such as body weight and BP, as well as their potential role in protecting renal function, may confer additional health benefits to patients with T2D.…”