Euglycemic DKA (euDKA) as a presentation of COVID‐19

Dass, Bhagwan; Beck, Andrew; Holmes, Cody; Morton, Glenville

doi:10.1002/ccr3.3540

Cited by 12 publications

(12 citation statements)

References 17 publications

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“…Most patients developing euglycemic DKA may have a precipitating event. The commonly reported factors include surgery, infections including COVID-19, pericarditis, concurrent ketogenic/low carbohydrate diets, a recent change of diabetic regimen with reduction or omission of insulin dosages, nausea and vomiting, gastroparesis, pregnancy, and acute pancreatitis [12][13][14][15][16][17][18][19]. Diagnosis is often delayed or missed in these settings, like in our case presentation.…”

Section: Discussionmentioning

confidence: 90%

“…Typically, from most of the reported cases, eu-DKA has been managed similar to hyperglycemic DKA with intravenous insulin, fluids, and frequent monitoring of serum electrolytes until anion gap acidosis resolution [12][13][14][15][16][17][18][19]. But, patients could be conservatively managed like in our case.…”

Section: Discussionmentioning

confidence: 91%

“…Diagnosis is often delayed or missed in these settings, like in our case presentation. The reported blood glucose in these cases ranged from 127-212 mg/dL [12][13][14][15][16][17][18][19].…”

Section: Discussionmentioning

confidence: 99%

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Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Chandrakumar¹,

Chillumuntala²,

Singh³

et al. 2021

Cureus

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Euglycemic diabetic ketoacidosis (eu-DKA) is an uncommon and serious adverse event associated with the use of sodium-glucose cotransporter (SGLT-2) inhibitors. It is a state of increased anion gap metabolic acidosis with ketosis but in the setting of normal serum glucose levels. Diagnosis of this serious entity could easily be missed given the non-specific symptoms and the normal glucose measurements. This ketogenic state can be triggered by various stressors including infection, surgery, myocardial infarctions, omission of insulin dosage, as well as low carbohydrate diet. In this report, we present a case of eu-DKA in a 68-year-old woman with type 2 diabetes that occurred in the postoperative period of glaucoma surgery. She was started shortly before surgery on SGLT-2 inhibitor (ertugliflozin). While the diagnosis was initially missed, it was subsequently confirmed when she presented with reduced appetite, generalized fatigue, and constipation. Ertugliflozin was discontinued, and she was successfully treated with conservative management and without insulin drip. This case highlights the need to consider the diagnosis of eu-DKA in patients treated with SGLT-2 inhibitors since the diagnosis could easily be missed especially in the postoperative period with the non-characteristic symptomatology and normoglycemia.

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Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 91%

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Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Chandrakumar¹,

Chillumuntala²,

Singh³

et al. 2021

Cureus

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“…Euglycemic DKA is a rare life-threatening complication associated with the use of SGLT2 inhibitors in patients with type 2 diabetes that may be unnoticed, particularly in COVID-19 pandemic, due to the absence of significant hyperglycaemia, delaying its treatment [ 16 ]. Given their undisputed cardiovascular and renal benefits, these medications are common in patients with type 2 diabetes [ 107 ]. There are recommendations that patients using SGLT2 inhibitors should be monitored for ketosis using available home testing kits in case of infections and should discontinue the medication in case of SARS-CoV-2 while the administration of insulin is considered the safest pharmacotherapy choice [ 108 ].…”

Section: Discussionmentioning

confidence: 99%

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Alhumaid

Mutair

Alawi

et al. 2021

Diabetol Metab Syndr

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Background One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA). Objectives To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA. Design A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Methods Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient’s final treatment outcome (survival or death). Results Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399–638 mg/dl], 11.4% [IQR 9.9–13.5%], 7.16 [IQR 7.00–7.22], 10 mmol/l [IQR 6.9–13 mmol/l], and 24.5 mEq/l [18–29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07–15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38–7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37–5.17; p = 0.004] compared to those who survived. Conclusion DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

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“…

Euglycemic DKA (EuDKA) has been described in diabetic patients with poor oral intake, low carbohydrate/low calorie intake, decreased/missed insulin dose, infections, drug (cocaine) overdose, excessive alcohol consumption, surgical/ traumatic stress [2-9] and recent ly with COVID 19 infection [10,11] (Figure 1). The incidence of EuDKA has increased with introduction of the sodium glucose transporter 2 inhibitors (SGLT2i): Canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin, luseogliflosin, tofogliflozin, sotogliflozin [6,[7][8][9][10][11][12]. SGLT2 inhibitors are a new class of antihyperglycemic drugs which have gained widespread use

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confidence: 99%

Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

Olga¹,

Hector²,

Amando³

et al. 2021

Clin Diabetes Res

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Euglycemic DKA (euDKA) as a presentation of COVID‐19

Abstract: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Cited by 12 publications

References 17 publications

Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

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