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

Latif, Azka; Gastelum, Aheli Arce; Sood, Akshat; Reddy, Joseph Thilumala

doi:10.1136/dtb.2021.235117rep

Cited by 3 publications

(5 citation statements)

References 14 publications

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“…No case report was found of a patient who developed EDKA following the start of keto diet for three days duration and stopped all of their oral medication for 2 days. Multiple case reports discussed the development of EDKA in patients who are on a SGLT2 inhibitor after introducing a ketogenic diet for at least one week [13][14][15][16]. In our case, the patient's normal level of lactic acid rules out lactic acidosis as a side effect of metformin use as a cause of DKA.…”

Section: Discussionmentioning

confidence: 71%

“…Laboratory values upon presentation to the emergency department were as follows: glucose 135 mg/dl (70-110 mg/dl)/ 7.5 mmol/l (3.9-6.1 mmol/L), HbA1c 9.7% (4.4-5.6%), sodium 132 mmol/L (136-145 mmol/L), chloride 97 mmol/L (98-107 mmol/L), venous bicarbonate 6 mmol/L (22-26 mmol/L), anion gap 29 [6][7][8][11][12][13][14][15][16], urinary ketones 15 (3+) mmol/l, and urinary glucose 56 (4+) mmol/L. All lab values were taken from venous samples (Table 1).…”

Section: Case Reportmentioning

confidence: 99%

“…Empagliflozin, dapagliflozin, and canagliflozin have all been associated to cause euglycemic diabetic ketoacidosis as well [1,11,12]. Most cases that describe EDKA in patients who are taking SGLT2 inhibitors discuss it in patients who have been on SGLT2 for a period of time who then started a ketogenic diet for one week or more before developing EDKA during their treatment course [13][14][15][16]. A ketogenic diet is defined as a diet where there is significant decrease in the amount of carbohydrates consumed typically to less than 50 g per day with an increase in proportion of fat and protein consumed to very high percentages [17].…”

Section: Introductionmentioning

confidence: 99%

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Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

Alhemeiri

Alseddeeqi

2022

Case Reports in Endocrinology

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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.

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Section: Discussionmentioning

confidence: 71%

Section: Case Reportmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

Alhemeiri

Alseddeeqi

2022

Case Reports in Endocrinology

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“…After removing duplicate records, 762 were screened by title, abstract, and full-text based on eligibility criteria, of which 13 studies were included in the final review. [1][2][3][4][5][6][7][8][9][10][11][12][13] The details of our search results are clearly described in the PRISMA flowchart in Figure 1. All studies were case reports, as no observational studies or clinical trials were conducted on this novel topic.…”

Section: Resultsmentioning

confidence: 99%

Dietary Changes Leading to Euglycemic Diabetic Ketoacidosis in Sodium-Glucose Cotransporter-2 Inhibitor Users: A Challenge for Primary Care Physicians?

et al. 2022

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Background: The use of euglycemic diabetic ketoacidosis (EDKA) related to sodium-glucose cotransporter 2 inhibitors (SGLT2i) use in people with diabetes has been increasingly reported. The causes are multifactorial, and dietary changes in SGLT2i users were observed to trigger EDKA. A ketogenic diet or very low-carbohydrate diet (VLCD) enhances body ketosis by breaking down fats into energy sources, causing EDKA. This study aimed to understand the patient specific risk factors and clinical characteristics of this cohort.Methods: Several databases were carefully analyzed to understand the patients’ symptoms, clinical profile, laboratory results, and safety of dietary changes in SGLT2i’s. Thirteen case reports identifying 14 patients on a ketogenic diet and SGLT2i’s diagnosed with EDKA were reviewed.Results: Of the 14 patients, 12 (85%) presented with type-2 diabetes mellitus (DM) and 2 (15%) presented with type-1 DM. The duration of treatment with SGLT2i before the onset of EDKA varies from 1 to 365 days. The duration of consuming a ketogenic diet or VLCD before EDKA onset varies from 1 to 90 days, with over 90% of patients hospitalized <4 weeks after starting the diet. At presentation, average blood glucose was 167.50±41.80 mg/dL, pH 7.10±0.10, HCO<sub>3</sub> 8.1±3.0 mmol/L, potassium 4.2±1.1 mEq/L, anion-gap 23.6±3.5 mmol/L, and the average hemoglobin A1c was 10%±2.4%. The length of hospital stay ranged from 1 to 15 days. None of the patients were reinitiated on SGLT2i’s, and 50% (2/4) of the patients reported were on the ketogenic diet or VLCD upon patient questioning.Conclusion: Despite the popularity of the ketogenic diet and VLCD for weight loss, their use in diabetics taking SGLT2i’s is associated with EDKA. Physicians should educate patients with diabetes taking SGLT2i’s about the risk of EDKA. In addition, patients should be encouraged to include their physicians in any decision related to significant changes in diet or exercise routines. Further research is needed to address if SGLT2i’s should be permanently discontinued in patients with diabetes on SGLT2i and whether the ketogenic diet developed EDKA.

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“…It should be noted that the treatment with SGLT2i requires caution because of the diabetic ketoacidosis risk especially in patients with BMI below 27 kg/m2. (1,37,38) As regards GLP-1 RA, dulaglutide has shown effectiveness on reducing the glycosylated hemoglobin (HbA1C) levels in one-year follow-up, thus improving metabolic control. (39) In choosing the optimal treatment, the parameter that guides therapeutic management is the HbA1C value.…”

Section: Epidemiology Of Ladamentioning

confidence: 99%

Lada or Type 2 Diabetes Mellitus - A Challenging Diagnosis in Clinical Approach

Custură

Deteşan

Tilinca

et al. 2021

Acta Medica Transilvanica

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Latent autoimmune diabetes in adults (LADA) is a frequently encountered condition in medical practice. It should be suspected in patients where the type of the diabetes mellitus is not certain. LADA consists of features from both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), being a condition which is often unnoticed. Considered as type 1.5 diabetes mellitus, the lack of insulin requirement at disease onset makes it initially to be included in T2DM in terms of therapeutic management. The improvement of the screening methods allows the detection of LADA at an early stage, therefore medical intervention should be effective in preserving beta-cell function and to delay the progression of the disease.

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

Cited by 3 publications

References 14 publications

Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

Dietary Changes Leading to Euglycemic Diabetic Ketoacidosis in Sodium-Glucose Cotransporter-2 Inhibitor Users: A Challenge for Primary Care Physicians?

Lada or Type 2 Diabetes Mellitus - A Challenging Diagnosis in Clinical Approach

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