Euglycaemic diabetic ketoacidosis in bariatric surgery patients with type 2 diabetes taking canagliflozin

Niekerk, Christoffel Van; Wallace, James R.; Takata, Mark; Yu, Roger

doi:10.1136/bcr-2017-221527

Cited by 8 publications

(3 citation statements)

References 9 publications

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“…Precipitating factors for HDKA and EDKA were described in 57% (n¼27) of cases (Table 4). Dietary modifications were identified as the precipitating factor in 15 cases, of which VLCDs were attributed in 10 bariatric cases, 13,15,22,25,30,33,34,36,38 and the others were attributable to preoperative fasting and poor postoperative intake. Of these 15 cases, where a combination of surgery and diet changes were recognised as risk factors, the information on handling the SGLT2i was available in 14 reports.…”

Section: Precipitating Factorsmentioning

confidence: 99%

“…40 Radiological imaging was performed to rule out an anastomotic leak, infection, and bowel obstruction in three cases, 21,29,38 two of them were post-bariatric surgery. 29,38 Imaging to exclude pulmonary embolism (PE) and infection was required in one bariatric case, 15 and to exclude PE and anastomotic leak in another bariatric patient. 36 An EDKA presentation 6 weeks after sleeve gastrectomy needed imaging and gastroscopy.…”

Section: Treatmentmentioning

confidence: 99%

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Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

132

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Background: Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. Methods: We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. Results: Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. Conclusions: EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.

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Section: Precipitating Factorsmentioning

confidence: 99%

Section: Treatmentmentioning

confidence: 99%

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Thiruvenkatarajan

Meyer

Nanjappa

et al. 2019

British Journal of Anaesthesia

132

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“…It is described that approximately 3% of DKA admissions to the ER present normal glucose blood levels, but the incidence has recently grown with the introduction of sodium-glucose cotransporter 2 inhibitors (SGLT2-i), such as canagliflozin, as a step in the T2DM treatment [1,5,6]. Moreover, some studies report that ketone-associated effects in T1DM using SGLT2 inhibitors can be not only higher than 3%, but reaching almost 10%.…”

Section: Introductionmentioning

confidence: 99%

Postoperatory Euglycemic Diabetic Ketoacidosis: A Not So Rare Complication of Sglt2 Inhibitors

Londoño,

Lladó Vilar,

Londoño

et al. 2023

AJSCR

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Diabetic ketoacidosis is one of the most well-known complications of diabetes mellitus and is potentially fatal. It is characterized by a state of hyperglycemia (glycemic levels >300mg/dL), associated with metabolic ketoacidosis. It has been described that up to 3% of diabetic ketoacidosis can occur with blood glucose levels below 250 mg/dL, an incidence that has been increased since the introduction of SGLT2-i. We report the case of a female patient in her seventies, with a history of hypertension, dyslipidemia, ischemic heart disease and type 2 diabetes mellitus treated with insulin, metformin and canagliflozin. During the post-operative period of an elective surgery, she presented a decreased level of consciousness associated to metabolic acidosis. She was admitted to the ICU and required invasive mechanical ventilation and vasopressors. Euglycemic diabetic ketoacidosis was diagnosed and after treatment, she was discharged with no sequelae.

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

et al. 2023

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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.

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Euglycaemic diabetic ketoacidosis in bariatric surgery patients with type 2 diabetes taking canagliflozin

Cited by 8 publications

References 9 publications

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

Postoperatory Euglycemic Diabetic Ketoacidosis: A Not So Rare Complication of Sglt2 Inhibitors

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

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