Sodium-Glucose Cotransporter-2 Inhibitor–Associated Euglycemic Diabetic Ketoacidosis After Orthotopic Heart Transplant in a Prediabetic Patient: A Case Report

New Diabetic Medication Sodium-Glucose Cotransporter-2 Inhibitors Can Induce Euglycemic Ketoacidosis and Mimic Surgical Diseases: A Case Report and Review of Literature

“…The identified papers included reports about bariatric ( 1 , 27 , 31 – 37 ), cardiothoracic ( 2 , 38 – 46 ), neuro- ( 47 – 49 ), vascular ( 50 ), orthopedic ( 51 ), urologic ( 52 ), ophthalmologic ( 53 ), and visceral ( 2 , 49 , 54 , 55 ) surgery. Most of the interventions were elective, and therefore the time of withhold and restart were predominantly mentioned.…”

“…The onset of EDKA was recognized between POD 0 [withhold of SGLT2-I for 48 h prior to surgery ( 38 )] and 6 weeks after [under SGLT2-I intake ( 1 )] surgery, hence, reflecting a wide range of clinical presentation. Reported patients were between 42 ( 31 ) and 76 ( 2 ) years of age, were prescribed empagliflozin ( 2 , 33 , 37 – 45 , 47 – 50 , 55 ), ertugliflozin ( 53 ), canagliflozin ( 2 , 31 – 33 , 35 , 36 , 49 , 54 ), or dapagliflozin ( 1 , 27 , 35 , 41 , 46 , 51 , 54 ), and female gender was an assumed risk factor ( 56 ). A long history of diabetes duration (>10 years) and the use of oral antidiabetics with or without insulin application were reported as predisposing patients' characteristics ( 57 ).…”

“…In patients with T2DM on SGLT2-I therapy, ketone levels might reach dangerous levels once stress, infection, or perioperative fasting are present ( 25 ). Reported risk factors are prolonged fasting ( 27 ) and/or reduced oral intake ( 33 ) due to vomiting or dietary changes prior to weight loss surgery (very-low-calory diet) ( 34 ), huge weight loss after bariatric surgery ( 27 ), acute infection ( 38 ), basal insulin discontinuation and/or dose reduction before and/or after surgery ( 27 , 31 , 32 ), continuation of SGLT2-I medication perioperatively ( 46 , 55 ), or withholding within 24–48 h prior to elective interventions ( 47 , 54 ). Patients undergoing bariatric surgery might be at special risk for the development of EDKA because of surgical stress, perioperative diet changes, and prolonged fasting periods ( 31 , 34 , 36 , 37 , 52 , 59 , 61 ).…”

“…Patients undergoing bariatric surgery might be at special risk for the development of EDKA because of surgical stress, perioperative diet changes, and prolonged fasting periods ( 31 , 34 , 36 , 37 , 52 , 59 , 61 ). The incidence of EDKA in diabetic cardiac bypass surgery patients indicates a worrisome potential of this side effect ( 2 , 38 – 46 ).…”