Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter 2 Inhibitor Use in Two Patients Undergoing Pancreatectomy

Sodium-Glucose Cotransporter 2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis: The Other Side of the Coin!

Euglycemic diabetic ketoacidosis (EDKA) though rare is a life-threatening complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors. With their increasing use in the management of type 2 diabetes mellitus (T2DM) due to long-term beneficial effects, the incidence of this complication is on the rise. We report a case of a 58-year-old lady with a history of T2DM on multiple anti-diabetes medications including dapagliflozin for one year, who during intercurrent illness developed EDKA. Her blood sugar on admission was 203 mg/dL, and arterial blood gas showed high anion-gap metabolic acidosis (HAGMA) with ketonuria and ketonemia (blood beta-hydroxybutyric (BOHB) acid level: 5.4 mmol/L). Low carbohydrate intake, dehydration resulting from repeated vomiting, and skipping the previous two days' dose of insulin could have precipitated this condition. She was treated with intravenous fluids, insulin, 5% dextrose infusion, and potassium supplements with complete resolution of acidosis after about 90 hours. This case signifies the importance of awareness of the link between the use of SGLT2 inhibitors and EDKA and early recognition of this complication to reduce morbidity and mortality. Furthermore, it also emphasizes the need for clinicians to educate their patients taking these drugs to stop them during the intercurrent illness to prevent them from developing EDKA.

Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are commonly prescribed to manage patients with diabetes mellitus. These agents may rarely lead to the development of euglycemic diabetic ketoacidosis (EDKA), which may complicate the disease course of these patients.

AIM

To analyze the demographic profile, predisposing factors, symptomology, clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.

METHODS

We performed a systematic search of PubMed, Science Direct, Google Scholar and Reference Citation Analysis databases using the terms "canagliflozin" OR "empagliflozin" OR "dapagliflozin" OR "SGLT2 inhibitors" OR "Sodium-glucose cotransporter-2" AND "euglycemia" OR "euglycemic diabetic ketoacidosis" OR "metabolic acidosis". The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported EDKA secondary to SGLT2i. Furthermore, the data were filtered from the literature published in the English language and on adults (> 18 years). We excluded: (1) Conference abstracts; and (2) Case reports or series which did not have individual biochemical data. All the case reports and case series were evaluated. The data extracted included patient demographics, clinical symptomatology, clinical interventions, intensive care unit course, need for organ support and outcomes.

RESULTS

Overall, 108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included. The majority of patients were females (54.4%, n = 92), and the commonly reported symptoms were gastrointestinal (nausea/vomiting 65.1%, abdominal pain 37.3%) and respiratory (breathlessness 30.8%). One hundred and forty-nine (88.2%) patients had underlying type II diabetes, and the most commonly involved SGLT-2 inhibitor reported was empagliflozin (46.8%). A triggering factor was reported in most patients (78.7%), the commonest being acute severe infection (37.9%), which included patients with sepsis, coronavirus disease 2019, other viral illnesses, and acute pancreatitis. 61.5% were reported to require intensive unit care, but only a minority of patients required organ support in the form of invasive mechanical ventilation (13%), vasopressors (6.5%) or renal replacement therapy (5.9%). The overall mortality rate was only 2.4%.

CONCLUSION

Patients on SGLT2i may rarely develop EDKA, especially in the presence of certain predisposing factors, including severe acute infections and following major surgery. The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels, which may make the diagnosis challenging. Outcomes of EDKA are good if recognized early and corrective actions are taken. Hence, physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.

A retrospective analysis of the incidence, outcome and factors associated with the occurrence of euglycemic ketoacidosis in diabetic patients on sodium glucose co-transporter - 2 inhibitors undergoing cardiac surgery

Introduction

SGLT2i is a new class of drugs used for type 2 diabetes. SGLT2i are known to cause EuKA in the perioperative period. Euglycemic ketoacidosis (EuKA) can cause life-threatening metabolic acidosis in the perioperative setting. Though the event rate of SGLT2i associated diabetic ketoacidosis in nonoperative setting is low, incidence among peri-operative patients can be very high and remains unknown.

Aim

The aim of this study was to find the incidence, analyze outcome, and establish correlation between risk factors and EuKA in cardiac surgical patients on SGLT2i.

Materials and Methods

This is a retrospective study analyzing 24 cardiac surgical patients who were on SGLT2i for type 2 diabetes mellitus. Data collection included age, sex, BMI, preoperative HbA1C, albumin, creatinine, type of SGLT2i and timing of stopping before surgery, insulin administration in the immediate pre-operative period; use of CPB, GI infusion and inotropes in the intraoperative period; blood ketone, duration of ventilation, hydration status and length of postoperative stay in postoperative period. Patients were diagnosed to have EuKA if any one of the serially measured postoperative ketone values was more than 0.6 mmol/L (ketone positive). The collected data were used to find an association between the risk factors and the occurrence of EuKA.

Results

Of the 24 patients, 17 patients developed EuKA. (70.8.%). 10 of the 17 EuKA in our study required preoperative Insulin for diabetic control whereas none in the ketone negative patients required insulin. This was statistically significant (P = 0.019). Association of other factors to EuKA were not statistically significant.

Conclusion

Though the event rate of SGLT2i associated Diabetic ketoacidosis in nonoperative setting is low, (17), the occurrence of EUKA in cardiac surgical patients on SGLT2i in our study was 70.8% (17 out of 24 patients). Patients who require insulin in addition to other oral hypoglycemic drugs for immediate preoperative glycemic control are at risk for the development of SGLT2 inhibitor-induced EuKA postoperatively. Missing the diagnosis of EuKA is fatal in these patients. We couldn't make a diagnosis in our first patient whom we lost. Since it was diagnosed in all our study patients by measuring serial ketone values, there was no mortality and insignificant morbidity. Cessation of SGLT2i before surgery, expectant watch for blood ketones, and treatment with GI infusion reduce morbidity and mortality in cardiac surgical patients.

A Literature Review of the Therapeutic Perspectives of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (DKA), a side effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors, is a triad of high metabolic anion gap acidosis, raised serum and urine ketones, and serum glucose <250 mg/dl. SGLT2 inhibitors cause a carbohydrate deficit by glucosuria, which leads to an increased glucagon/insulin ratio, the metabolic shift from glucose to lipid utilization causing ketogenesis, and hence euglycemic DKA. Additional factors like the ketogenic diet, illness, surgery, and pregnancy contribute to precipitating these episodes.

Keywords search included “Euglycemic DKA and SGLT2 inhibitors” in PubMed and Google Scholar, to compile data from existing articles that provide information on the withholding and restarting period of the drug after a euglycemic DKA episode.

SGLT2 inhibitors, used in the treatment of type 2 DM, have an average half-life of 11-13 hours, so most articles suggested withholding the drug three days before any elective surgery but some articles suggested a longer withholding period based on other precipitating factors contributing to euglycemic DKA. Hence, we came up with patient inclusion criteria and concomitant therapies review that we need to consider in making this decision. In addition, a multidisciplinary approach is required when laying out guidelines for restarting the drug to have a unanimous approach.

After reviewing the existing literature, it is clear that concrete guidelines are required to decide on drug withholding and restarting periods after a euglycemic DKA episode, as they vary among different institutions and different specialties. We believe it is crucial to consider patient inclusion criteria and concomitant therapies in forming those guidelines.

An Unsuspected Case of Euglycemic Diabetic Ketoacidosis With Twists

Euglycemic diabetic ketoacidosis (EDKA) is defined by acidosis, ketones in serum and urine, and a high anion gap (AG) with a normal glucose level. Sodium-glucose cotransporter-2 (SGLT2) inhibitor has become one of the most common causes of EDKA. We present one of the lowest presenting blood glucose levels for the EDKA in the setting of SGLT2 inhibitor use. A 34-year-old female with a two-year history of type 2 diabetes mellitus (T2DM) presented after accidental ingestion of a metal clip and lack of oral intake for 28 hours. She reported a recent intentional weight loss of 60 lbs. She takes metformin 1000 mg twice daily and empagliflozin 25 mg daily. An urgent endoscopy was planned in the intensive care unit given the proximal location of the foreign body. The basic metabolic profile after the procedure demonstrated a glucose level of 75 mg/dL, bicarbonate level of 11 mmol/L, and AG of 17 mmol/L. The venous pH was 7.27 with a partial pressure of carbon dioxide of 30 mmHg. The urinalysis showed a glucose level greater than 500 μmol/L with a ketone level of 80 μmol/L. The blood and urine toxicology screening results were unremarkable. The patient was treated for EDKA with the administration of intravenous (IV) dextrose 5% in water with subsequent initiation of IV insulin. The assessment of her insulin reserve revealed a low C-peptide of 0.36 ng/mL, a high glutamic acid decarboxylase level greater than 250 IU/mL, and high zinc transporter 8 (ZnT8) antibodies of 42 U/mL, consistent with an undiagnosed transition to latent autoimmune diabetes in adults (LADA). The blood glucose levels for previously reported cases remain between 90 and 250 mg/dL. In this case, the combination of a low carbohydrate diet and prolonged starvation may have led to the impressively low glucose. Additionally, the SGLT2 inhibitor use in patients with LADA serves as one of the known risk factors for EDKA. EDKA poses a diagnostic challenge, especially in the ICU setting where there exists a myriad of causes for high AG metabolic acidosis. Additionally, many of the ICU patients are in a ketotic state brought on by prolonged starvation. Therefore, prompt diagnosis and treatment for EDKA require careful history taking and complete investigation for other causes of high AG metabolic acidosis.

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

Background

Euglycemic diabetic ketoacidosis (EDKA) is a potentially life-threatening condition and a reported side effect of antidiabetic sodium-glucose-cotransporter-2-inhibitors (SGLT2-I). The analysis of the herein presented case and its management formed the incentive to prepare this multidisciplinary work and includes an overview about perioperative SGLT2-I-induced ketoacidosis.

Method

A PubMed search on relevant entries was conducted combining the terms “euglycemic diabetic ketoacidosis” AND “surgery.”

Results

A total of 33 articles on SGLT2-I-induced ketoacidosis in the context of surgical treatment were identified. According to this literature research risk factors for the development are infection, perioperative fasting, surgical stress, and insulin dose reduction.

Conclusion

Unspecific symptoms mimicking acute abdomen and normoglycemia can lead to delayed diagnosis of EDKA and might harm patients under SGLT2-I therapy in the perioperative setting. SGLT2-I medication should be withheld for at least 24–48 h prior to surgery according to this review of literature and restarted only in stable clinical conditions to avoid the severe complication of EDKA.

Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors: A systematic review and quantitative analysis

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Sodium-Glucose Co-transporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Bariatric Surgery: A Case and Literature Review

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce cardiovascular, kidney, and overall mortality. SGLT2i are also associated with a rare adverse event, euglycemic diabetic ketoacidosis (EDKA). This report describes a case of EDKA one day after bariatric surgery in a 51-year-old female with type 2 diabetes mellitus managed with the SGLT2i, canagliflozin. She was following a ketogenic diet for three weeks prior to surgery. The patient made a steady recovery with rapid anion gap closure followed by prolonged non-anion gap metabolic acidosis. Her medical record was tagged with a life-threatening reaction to SGLT2i. The risk of EDKA from SGLT2i may be increased by a low carbohydrate diet or postoperative status. Our case was complicated by hypokalemia, exemplifying the need for aggressive electrolyte management. Further guidance is needed to manage risk factors provoking EDKA and the use of SGLT2i therapy after an episode of EDKA.

Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers

Diabetic ketoacidosis (DKA) is an acute and significant life-threatening complication of diabetes. The association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) with euglycemic diabetic ketoacidosis (EDKA) has been well reported. This literature review was conducted to understand the mechanism of EDKA and identify the potential risk factors and precipitants for patients taking SGLT2i. After reviewing the published literature between 2010 and 2020, 32 articles are included in the final review. The underlying mechanism is mainly enhanced lipolysis and ketone body reabsorption. SGLT2i also stimulates pancreatic alpha cells and inhibits beta cells, causing an imbalance in glucagon/insulin levels, further contributing to lipolysis and ketogenesis. Most patients were diagnosed with blood glucose less than 200 mg/dL, blood pH <7.3, increased anion gap, increased blood, or urine ketones. Perioperative fasting, pancreatic etiology, low carbohydrate or ketogenic diet, obesity, and malignancy are identified precipitants in this review. As normoglycemia can conceal the underlying acidosis, physicians should be cognizant of the EDKA diagnosis and initiate prompt treatment. Patient education on risk factors and triggers is recommended to avoid future events.

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors and microvascular outcomes in patients with type 2 diabetes: systematic review and meta-analysis

PURPOSE

The effect of the sodium-glucose 2 (SGLT-2) inhibitors on microvascular complications remains uncertain. We performed a systematic review to determine the efficacy of the SGLT-2 inhibitors on microvascular outcomes in patients with type 2 diabetes.

METHODS

A comprehensive search was performed using Ovid, MEDLINE, EMBASE, Web of Science, and Scopus from inception to May 2019. Randomized trials comparing SGLT-2 inhibitors with placebo or other medication for type 2 diabetes for ≥ 4 weeks were included. Diabetes-related microvascular complications such as nephropathy, retinopathy, neuropathy, and peripheral vascular disease were evaluated. A random-effect model using mean differences for continuous outcomes and risk ratio for dichotomous outcomes was used to synthesize data. PROSPERO (CRD 42017076460).

RESULTS

A total of 40 RCTs with overall moderate quality of evidence were included. SGLT-2 inhibitors reduced the risk of renal-replacement therapy (0.65; 95% CI 0.54-0.79), renal death (0.57; 95% CI 0.49-0.65), and progression of albuminuria (0.69; 95% CI 0.66-0.73). Conversely, they appeared ineffective in maintaining eGFR (0.33; 95% CI - 0.74 to 1.41) or reducing serum creatinine (- 0.07; 95% CI - 0.26 to 0.11), whereas urine albumin-creatinine ratio (- 23.4; 95% CI - 44.6 to - 2.2) was reduced. Risk of amputation was non-significant (1.30; 95% CI 0.93-1.83). No available data were found regarding neuropathy and retinopathy to perform a quantitative analysis.

CONCLUSION

SGLT-2 inhibitors may reduce the risk of renal patient-important outcomes but fail to improve surrogate outcomes. Apparently, no increased risk of amputations was observed with these medications. No data were available regarding other microvascular complications.

Glycemic Management in the Operating Room: Screening, Monitoring, Oral Hypoglycemics, and Insulin Therapy

PURPOSE OF REVIEW

This review provides a literature update and practical outline for the management of diabetes and stress hyperglycemia for adult surgical patients in the pre- and intraoperative settings.

RECENT FINDINGS

Hyperglycemia in surgical patients has been associated with increased risk of complication in both diabetic and non-diabetic patients in the perioperative setting. While current recommended perioperative blood glucose target is < 180 mg/dL (10 mmol/L), optimal outcomes may require different treatment targets for diabetic versus non-diabetic patients. Hemoglobin A1C level is associated with elevated risk of hyperglycemia and adverse outcomes, but there is insufficient evidence to recommend routine preoperative testing or optimal values in elective surgical patients. Day of surgery blood glucose testing and treatment are recommended in the perioperative period, and anesthetic management includes appropriate patient selection for use of subcutaneous insulin, intravenous insulin infusions, and insulin pumps. Additionally, administration of both intravenous and perineural dexamethasone is associated with increased blood glucose levels and clinicians should consider the risk benefit ratio in surgical patients. For enhanced recovery after surgery protocols, further evidence is needed to support routine use of carbohydrate loading in diabetic patients. Optimal perioperative care includes screening at-risk patients, use of preoperative oral hypoglycemics and home insulin, anesthetic type and medication selection, blood glucose testing, and treatment for hyperglycemia in the operating room. Partnerships with surgery and endocrinology teams aid optimal postoperative management and discharge planning.