Inpatient Perioperative Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter-2 Inhibitors – Lessons From a Case Series and Strategies to Decrease Incidence

Mehta, Paras B; Robinson, Andrew; Burkhardt, Dan; Rushakoff, Robert J

doi:10.1016/j.eprac.2022.06.006

Cited by 28 publications

(5 citation statements)

References 28 publications

(30 reference statements)

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“…Study by Mehta, et al (2022) 12 with the majority (79.1%) being non-emergent patients. 625 (47.8%) of 1307 patients were prescribed empagliflozin, 447 (34.2%) were prescribed canagliflozin, 214 (16.4%) were prescribed dapagliflozin, and 21 (1.6%) were prescribed ertugliflozin.…”

Section: Resultsmentioning

confidence: 97%

Perioperative Diabetic Ketoacidosis Associated With Sodium-Glucose Co-Transporter-2 Inhibitors : A Systematic Review

Manurung

2023

JARMHS

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DKA or diabetic ketoacidosis is an emergency condition caused by hyperglycemia in which excessive acid is produced in the blood. Patients with type 1 and type 2 diabetes who undergo surgery, have an infection, or are under extreme stress can also develop DKA. The body generates the hormone adrenaline to combat infection and stress, but this can have a negative effect on blood glucose levels (adrenaline is counterinsulin). This can worsen if the patient refuses to take diabetes medication or inject insulin during stressful or infectious situations. The fundamental components of the pathophysiological mechanisms at play in diabetic ketoacidosis (DKA) include shifts in hormone levels and the ensuing inflammatory response. Alterations in the concentration of hormones lead to shifts in the production and consumption of glucose, as well as an increase in lipolysis and the formation of ketone bodies. Canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin are agents approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes mellitus (DM) in adults. Acting on proteins, the four agents are SGLT2 inhibitor class agents. SGLT-2 is expressed in the kidney's proximal tubule. This may result in a decrease in filtered glucose reabsorption, a decrease in the renal threshold for glucose (RTG), and an increase in glucose excretion via urine. Diabetes patients treated with sodium–glucose transport protein 2 (SGLT2) inhibitors have also been reported to experience DKA. The results of a study indicate that DKA is uncommon among T2DM patients treated with SGLT2 inhibitors.

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Section: Resultsmentioning

confidence: 97%

Perioperative Diabetic Ketoacidosis Associated With Sodium-Glucose Co-Transporter-2 Inhibitors : A Systematic Review

Manurung

2023

JARMHS

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“… 9 In the case of a planned surgery, it is necessary to discontinue the drug for at least three days before the operation. 10 …”

Section: Discussionmentioning

confidence: 99%

Case 11: A 31-Year-Old Woman With Abdominal Pain

et al. 2023

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“…Some studies have recommended holding SGLT2 inhibitors for 72 hours prior to surgeries. Mehta et al conducted a retrospective cohort study that found that SGLT2 inhibitor-induced euglycemic DKA was less likely to occur in patients undergoing non-emergent procedures when compared to patients undergoing emergent surgeries [ 18 ]. The authors attributed this difference to the ability to stop SGLT2 inhibitor use three days before the non-emergent procedures, which was not possible for the emergent procedures.…”

Section: Discussionmentioning

confidence: 99%

A Case of Prolonged Recovery for Post-percutaneous Coronary Intervention (PCI) Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a 28-Year-Old

Petersen,

Gyabaah,

Sotelo

et al. 2023

Cureus

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Euglycemic diabetic ketoacidosis (DKA) is a rare, but clinically important, presentation that can lead to significant morbidity and mortality in patients with diabetes mellitus. It has been associated with multiple etiologies, including sodium-glucose cotransport-2 (SGLT2) inhibitor use. This case report details the presentation of a 28-year-old male patient who was recently diagnosed with non-ST elevated myocardial infarction (NSTEMI) status post-percutaneous coronary intervention (PCI) to left anterior descending (LAD) and type 2 diabetes mellitus (T2DM) and discharged on a new medical regiment that included an SGLT2 inhibitor. The patient presented five days later with dyspnea, nausea, and vomiting. On initial evaluation, he had tachycardia and hypertension. Lab work revealed hyperkalemia, metabolic anion gap acidosis, and the presence of ketones and glucose in the urine, which led to the diagnosis of euglycemic DKA. The patient was started on intravenous (IV) insulin, bicarbonate, and D5 ½ normal saline (NS) and required five days of continuous treatment for the anion gap to close. Considering studies have shown that SGLT2 inhibitors are associated with euglycemic DKA, it is proposed that the use of an SGLT2 inhibitor in this newly diagnosed, post-PCI patient led to the development of euglycemic DKA. DKA most commonly resolves within 24 hours of treatment; however, our patient did not recover until after 120 hours of treatment. Recent studies have suggested that SGLT2-inhibitor euglycemic DKA may be associated with longer recovery time; however, there is still a need to further research the consistency of these findings and quantify the estimated duration of treatment across populations. There is also a need for investigation into how co-morbid factors, such as a recent NSTEMI and PCI, may affect recovery times or predispose patients who are taking SGLT2-inhibitors to develop euglycemic DKA as SGLT2 inhibitors are being more widely prescribed. This case report highlights the importance of creating more detailed and evidence-based guidelines for prescribing SGLT2 inhibitors for patients with diabetes and encourages more research into the expected duration of treatment for patients with SGLT2-induced euglycemic DKA and factors that may affect it.

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Inpatient Perioperative Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter-2 Inhibitors – Lessons From a Case Series and Strategies to Decrease Incidence

Cited by 28 publications

References 28 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

Case 11: A 31-Year-Old Woman With Abdominal Pain

A Case of Prolonged Recovery for Post-percutaneous Coronary Intervention (PCI) Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a 28-Year-Old

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