Euglycemic Diabetic Ketoacidosis, SGLT-2 Inhibitors and COVID-19; The Murphy Law of COVID-19

Abstract

Euglycemic Diabetic ketoacidosis (DKA) is a rare complication in type II Diabetic patients who are taking sodiumglucose cotransporter-2 (SGLT-2) inhibitors. We present a case of euglycemic DKA in a type II diabetic patient taking SGLT-2 inhibitors with a positive Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) infection that was diagnosed early and treated with subcutaneous short-acting insulin. A 57-year-old man presented to our emergency department for sudden fall and dysarthria with a few days history of shortness of breath, fever and nausea. CT head at presentation showed segmental occlusion of right internal carotid artery(ICA). Nasal swab was positive with SARS-CoV2 PCR. Initial labs remarkable for bicarbonate of 17 meq/L, arterial pH 7.14 with an anion gap of 17 and PCO2 was 41. His serum blood glucose was 248mg/dl and lactate at 1.0 mmol/L. His past medical history was significant for type II diabetes (on Empagliflozin and Metformin) and extensive coronary artery disease with multiple stents, on dual anti-platelet therapy (DAPT). He underwent interventional radiology (IR) guided thrombectomy of right ICA and was admitted to ICU for post-stroke care. Due to aforementioned labs, we immediately checked his serum ketones which were elevated at 0.58mmol/L and the diagnosis of euglycemic-DKA secondary to SGLT-2 inhibitor use was made. Since the metabolic acidosis and ketonemia were still fairly in the early stages, we decided to manage it with subcutaneous short-acting insulin. The anion gap was closed within the next 12 hours. Euglycemic DKA is a known complication of SGLT-2 inhibitors with high morbidity and mortality. The reported incidence of euglycemic DKA with empagliflozin is 0.2 to 0.6 per 1,000 patient-years. Recently, a few case reports have been published sharing a correlation with SARS-CoV2 infection. This infection causes a state of profound inflammation and stress, making lab values in these patients widely deranged which can muddle the clinical picture. Since this infection also worsens the glycosuria seen with the use of SGLT-2 inhibitors, ICU physicians must pay close attention to this complication in diabetic patients. We propose that the incidence of developing euglycemic DKA with SGLT-2 inhibitor use may be higher in SARS-CoV2 infection and more research may prove a positive correlation between the two.