Euglycemic Diabetic Ketoacidosis with SGLT2 Inhibitor Use in A Patient on The Atkins Diet: A Unique Presentation of A Known Side Effect

Sood, M.; Simón, Barbara; Ryan, Kathleen F.; Zebrower, Marcus

doi:10.4158/ep171860.cr

Cited by 8 publications

(9 citation statements)

References 7 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Table compares and contrasts cases reported in literature. 17 , 18 , 19 , 20 , 21 To our knowledge, our case is the first report of euDKA occurring after just 1 dose of an SGLT2 inhibitor while on a ketogenic diet. Table indicates the number of days a patient received an SGLT2 inhibitor before developing euDKA, which ranged from 1 day (our study) to 365 days.…”

Section: Discussionmentioning

confidence: 66%

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature

Mistry

Eschler

2021

AACE Clinical Case Reports

View full text Add to dashboard Cite

Objective Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a relatively novel class of oral medications for the treatment of type 2 diabetes mellitus (T2DM). Their use has increased recently due to their beneficial renal and cardiovascular outcomes, but they come with the rare risk of diabetic ketoacidosis (DKA) at normal or slightly elevated glucose values, termed euglycemic DKA (euDKA). Recently, carbohydrate-deprived, ketogenic diets have gained popularity due to benefits of weight loss and improved control of T2DM. We describe 2 patients with T2DM who developed euDKA caused by SGLT2 inhibitor use while on a ketogenic diet and provide a review of the literature. Methods We describe the hospital course, laboratory data, and treatment of 2 patients and provide a literature review. Results Both of our patients were found to have normal or mildly elevated serum glucose levels, with an elevated anion gap and ketosis, representative of euDKA. The first patient developed euDKA after only 1 dose of empagliflozin, while the second patient developed euDKA after only 1 week of being on a ketogenic diet while on an SGLT2 inhibitor. Conclusion While there have been a few reports of euDKA with SGLT2 inhibitors and ketogenic diets, many physicians prescribing these medications may not be aware of this association. Therefore, they must inform their patients to avoid a ketogenic diet if on an SGLT2 inhibitor. If a patient presents with symptoms of DKA and is eating a carbohydrate-free diet while taking an SGLT2 inhibitor, there should be a low threshold to screen for DKA.

show abstract

Section: Discussionmentioning

confidence: 66%

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature

Mistry

Eschler

2021

AACE Clinical Case Reports

View full text Add to dashboard Cite

show abstract

“…On review of the literature, this is not the first case of DKA in a patient on an SGLT2 inhibitor following a ketogenic or low-carbohydrate diet [ 7 – 10 ]. Another case reports a similar story of a 44-year-old man who had been on sitagliptin, metformin, and an Atkins diet, and 3-4 days after starting canagliflozin, he developed euglycemic DKA which was first missed by the ED and later recognized by his primary internist [ 10 ]. As in our case, our patient had already presented with euglycemic DKA to the ED, which was diagnosed as dehydration and starvation ketosis.…”

Section: Discussionmentioning

confidence: 99%

A Case of Diabetic Ketoacidosis in a Patient on an SGLT2 Inhibitor and a Ketogenic Diet: A Critical Trio Not to Be Missed

Steinmetz-Wood

Gilbert

Menson

2020

Case Reports in Endocrinology

View full text Add to dashboard Cite

Results from major clinical trials have shown significant cardiorenal-protective benefits of SGLT2 inhibitors in patients with type 2 diabetes (T2DM), leading to increased popularity. A rare but serious side effect of SGLT2 inhibitors is euglycemic diabetic ketoacidosis (EDKA), which presents more covertly but has been described. Identification and report of modifiable risk factors would be an important step in helping clinicians appropriately counsel patients. In this case report, we present DKA in a patient on an SGLT2 inhibitor and ketogenic diet (KD). A 47-year-old male with a history of poorly controlled T2DM on metformin and empagliflozin presented to the emergency department (ED) with several days of pharyngitis, dyspnea, emesis, abdominal pain, and anorexia. Of note, one month prior to this event, he presented to the ED with malaise and was found to have an anion gap of 21, a bicarbonate level of 13 mmol/L, a pH level of 7.22, 3+ ketonuria, and a glucose level of 7 mmol/L (127 mg/dl). Additional workup was negative, and findings were attributed to his KD. His use of empagliflozin was not identified on his medication list. At second presentation, the patient was tachypneic and tachycardic and had mild abdominal tenderness. Labs revealed anion gap 28, bicarbonate 5 mmol/l, pH 6.94, 3+ ketonuria, glucose 14.9 mmol/L (269 mg/dl), and beta-hydroxybutyrate 8.9 mmol/L. The patient was diagnosed with DKA and was treated accordingly. With closure of anion gap, the patient was transitioned to insulin and metformin, and his empagliflozin was discontinued indefinitely. Before prescribing this medication class, physicians should inquire about low-carbohydrate diets given the higher risk for DKA, though knowledge of this risk is still not widespread.

show abstract

“…It occurs when insulin is deficient, and glucagon and other counter-regulatory stress hormones are increased in comparison [ 1 ]. This increases fat utilization for energy, making ketones, which leads to clinical features of hyperglycemia, ketosis, and electrolyte abnormalities [ 1 , 2 ]. DKA classically presents with a very high blood glucose level and dehydration, but a standard or mildly high blood glucose level can also be seen [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…This increases fat utilization for energy, making ketones, which leads to clinical features of hyperglycemia, ketosis, and electrolyte abnormalities [ 1 , 2 ]. DKA classically presents with a very high blood glucose level and dehydration, but a standard or mildly high blood glucose level can also be seen [ 2 ]. The Food and Drug Administration defines it as euglycemic DKA (EDKA) when the serum glucose level is ≤250 mg/dL with features of DKA [ 1 ].…”

Section: Introductionmentioning

confidence: 99%

“…SGLT2i targets the action of protein SGLT2i in the kidneys by preventing glucose reabsorption in the proximal renal tubules [ 3 ]. They ultimately cause glycosuria, inducing decreased insulin levels, and causes greater lipid utilization than glucose, leading to increased production of ketones [ 1 , 2 ]. This ketogenic state lowers the threshold for DKA, especially if there are other precipitating factors [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

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

et al. 2022

View full text Add to dashboard Cite

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.

show abstract

Euglycemic Diabetic Ketoacidosis with SGLT2 Inhibitor Use in A Patient on The Atkins Diet: A Unique Presentation of A Known Side Effect

Cited by 8 publications

References 7 publications

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature

Euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors and a Ketogenic Diet: A Case Series and Review of Literature

A Case of Diabetic Ketoacidosis in a Patient on an SGLT2 Inhibitor and a Ketogenic Diet: A Critical Trio Not to Be Missed

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

Contact Info

Product

Resources

About