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Memeti B, Brombacher F, Perger L, Russmann S. Mottling as an Early Sign of Euglycemic Ketoacidosis Induced by SGLT-2 Inhibitors. Eur J Case Rep Intern Med 2025; 12:005210. [PMID: 40270662 PMCID: PMC12013240 DOI: 10.12890/2025_005210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2025] [Accepted: 02/24/2025] [Indexed: 04/25/2025] Open
Abstract
Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have shown benefits in managing heart failure, renal insufficiency and type 2 diabetes, but euglycemic ketoacidosis, while rare, has been reported in several patients on those medications. Therefore, their potential for inducing ketoacidosis, even in the presence of normal glucose levels, requires careful monitoring. We describe the case of a 78-year-old woman with type 2 diabetes treated with the SGLT-2 inhibitor dapagliflozin and the biguanide metformin, who presented after several days of reduced food and fluid intake due to nausea and diarrhoea to the emergency department. A few hours after admission to the medical ward with a working diagnosis of infectious gastroenteritis her condition deteriorated, and mottling served as an early sign of life-threatening euglycemic ketoacidosis. The mottling score increased in parallel with the National Early Warning Score (NEWS). She was treated with intravenous fluids, continuous insulin therapy and supportive measures, resulting in rapid clinical improvement. This report highlights the importance of early recognition to prevent serious complications and underscores that mottling might be a valuable early sign in addition to classical tools such as the NEWS. Although rare, euglycemic ketoacidosis can be precipitated by factors such as starvation, dehydration or infections in patients taking SGLT-2 inhibitors. The risk might be higher in individuals on SGLT-2 inhibitors and metformin. Timely intervention and metabolic correction are essential for improving outcomes in these patients, particularly when they present with atypical symptoms. LEARNING POINTS Mottling can serve as an early clinical indicator of euglycemic ketoacidosis (EKA) in patients treated with sodium-glucose co-transporter-2 (SGLT-2) inhibitors, even in the absence of circulatory shock, highlighting the importance of timely detection and intervention.Factors such as starvation, dehydration or infections can precipitate EKA in patients using SGLT-2 inhibitors, emphasising the need for careful monitoring in at-risk populations.Discontinuation of SGLT-2 inhibitors, rapid metabolic correction using fluids and insulin and avoidance of unnecessary antibiotics are essential for effective management and recovery from EKA.
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Affiliation(s)
- Besard Memeti
- Department of Internal Medicine, Klinic Hirslanden, Zurich, Switzerland
| | - Felix Brombacher
- Department of Internal Medicine, Klinic Hirslanden, Zurich, Switzerland
| | - Ludwig Perger
- Department of Internal Medicine, Klinic Hirslanden, Zurich, Switzerland
| | - Stefan Russmann
- Department of Internal Medicine, Klinic Hirslanden, Zurich, Switzerland
- Drugsafety.ch, Kuesnacht, Switzerland
- University of Nicosia Medical School, Engomi, Cyprus
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Amin AM, Mostafa H, Khojah HMJ. Insulin resistance in Alzheimer's disease: The genetics and metabolomics links. Clin Chim Acta 2023; 539:215-236. [PMID: 36566957 DOI: 10.1016/j.cca.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Alzheimer's disease (AD) is a neurodegenerative disease with significant socioeconomic burden worldwide. Although genetics and environmental factors play a role, AD is highly associated with insulin resistance (IR) disorders such as metabolic syndrome (MS), obesity, and type two diabetes mellitus (T2DM). These findings highlight a shared pathogenesis. The use of metabolomics as a downstream systems' biology (omics) approach can help to identify these shared metabolic traits and assist in the early identification of at-risk groups and potentially guide therapy. Targeting the shared AD-IR metabolic trait with lifestyle interventions and pharmacological treatments may offer promising AD therapeutic approach. In this narrative review, we reviewed the literature on the AD-IR pathogenic link, the shared genetics and metabolomics biomarkers between AD and IR disorders, as well as the lifestyle interventions and pharmacological treatments which target this pathogenic link.
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Affiliation(s)
- Arwa M Amin
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah, Saudi Arabia.
| | - Hamza Mostafa
- Biomarkers and Nutrimetabolomics Laboratory, Department of Nutrition, Food Sciences and Gastronomy, Food Innovation Network (XIA), Nutrition and Food Safety Research Institute (INSA), Facultat de Farmàcia i Ciències de l'Alimentació, Universitat de Barcelona (UB), 08028 Barcelona, Spain; Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Hani M J Khojah
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah, Saudi Arabia
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Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor. Case Rep Endocrinol 2022; 2022:4101975. [PMID: 35282610 PMCID: PMC8906987 DOI: 10.1155/2022/4101975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 12/13/2022] Open
Abstract
Background Sodium glucose cotransporter-2 (SGLT2) inhibitors have been proven to be very effective in the management of type II diabetes. These medications can cause adverse drug reactions such as genital mycotic infections. Another critical adverse drug reaction is euglycemic diabetic ketoacidosis (EDKA) under the setting of other contributing risk factors for developing diabetic ketoacidosis. Case Presentation. We report a case of a 45-year-old gentleman with type 2 diabetes mellitus on empagliflozin, metformin, and glimepiride who presented with abdominal pain, fatigue, and vomiting. Of note, he started a ketogenic diet three days before his presentation and self-stopped his antidiabetic medications two days before his presentation. The patient was found to have euglycemic diabetic ketoacidosis and was treated as per the protocol. He was discharged on metformin and pioglitazone. Two weeks following discharge, canagliflozin was added. Conclusion Euglycemic diabetic ketoacidosis could still be precipitated despite discontinuation of SGLT2I under a ketogenic diet. Discussion related to the initiation of a ketogenic diet should occur between the care provider and the patient.
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Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes 2021; 12:514-523. [PMID: 33995841 PMCID: PMC8107974 DOI: 10.4239/wjd.v12.i5.514] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/01/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Sandeep Chaudhary
- Department of Endocrinology, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | | | - Aanchal Singh
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
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Ata F, Yousaf Z, Khan AA, Razok A, Akram J, Ali EAH, Abdalhadi A, Ibrahim DA, Al Mohanadi DHSH, Danjuma MI. SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort. Sci Rep 2021; 11:10293. [PMID: 33986421 PMCID: PMC8119406 DOI: 10.1038/s41598-021-89752-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/30/2021] [Indexed: 12/20/2022] Open
Abstract
Euglycemic diabetic ketoacidosis (EuDKA) secondary to Sodium-glucose co-transporter-2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2D) is a rare but increasingly reported phenomenon. Not much is known about the burden of EuDKA in patients on SGLT2i or the associated factors. This retrospective cohort study tries to delineate the differences in factors associated with the development of EuDKA as compared to hyperglycemic DKA. We conducted a multicentre, retrospective study across three tertiary care centers under Weill Cornell affiliated-Hamad Medical Corporation, Qatar. The cohort comprised of T2D patients on SGLT2i who developed DKA between January 2015 to December 2020. The differences between the subjects who developed EuDKA or hyperglycaemic DKA (hDKA) were analyzed. A total of 9940 T2D patients were on SGLT2i during 2015-2020, out of which 43 developed DKA (0.43%). 25 developed EuKDA, whereas 18 had hDKA. The point prevalence of EuDKA in our cohort was 58.1%. EuDKA was most common in patients using canagliflozin, followed by empagliflozin and Dapagliflozin (100%, 77%, and 48.3%, respectively). Overall, infection (32.6%) was the most common trigger for DKA, followed by insulin non-compliance (13.7%). Infection was the only risk factor with a significant point estimate between the two groups, being more common in hDKA patients (p-value 0.006, RR 2.53, 95% CI 1.07-5.98). Canagliflozin had the strongest association with the development of EuDKA and was associated with the highest medical intensive care unit (MICU) admission rates (66.6%). In T2D patients on SGLT2i, infection is probably associated with an increased risk of developing EuDKA. The differential role of individual SGLT2i analogs is less clear and will need exploration by more extensive prospective studies.
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Affiliation(s)
- Fateen Ata
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar.
- Division of Health Care Sciences, Dresden International University, Dresden, Germany.
| | - Adeel Ahmad Khan
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
| | - Almurtada Razok
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
| | - Jaweria Akram
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
| | | | - Ahmed Abdalhadi
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
| | | | - Dabia Hamad S H Al Mohanadi
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
- Weill Cornell Medicine Qatar, Doha, Qatar
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed I Danjuma
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, PO BOX 3050, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
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Amin AM. The metabolic signatures of cardiometabolic diseases: Does the shared metabotype offer new therapeutic targets? LIFESTYLE MEDICINE 2021. [DOI: 10.1002/lim2.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Arwa M. Amin
- Department of Clinical and Hospital Pharmacy College of Pharmacy Taibah University Medina Saudi Arabia
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Latif A, Gastelum AA, Sood A, Reddy JT. Euglycaemic diabetic ketoacidosis in a 43-year-old woman with type 2 diabetes mellitus on SGLT-2 inhibitor (empagliflozin). Drug Ther Bull 2021; 59:93-95. [PMID: 33509834 DOI: 10.1136/dtb.2021.235117rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Azka Latif
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA.,CHI Creighton Health, Creighton University Medical Center-University Campus, Omaha, Nebraska, USA
| | - Aheli Arce Gastelum
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
| | - Akshat Sood
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
| | - Joseph Thilumala Reddy
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
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Affiliation(s)
- Pamela Dyson
- OCDEM, Oxford University NHS Foundation Trust, Oxford, UK; and NIHR Biomedical Research Centre Oxford UK
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Latif A, Gastelum AA, Sood A, Reddy JT. Euglycaemic diabetic ketoacidosis in a 43-year-old woman with type 2 diabetes mellitus on SGLT-2 inhibitor (empagliflozin). BMJ Case Rep 2020; 13:13/6/e235117. [PMID: 32513767 DOI: 10.1136/bcr-2020-235117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
We report a case of euglycaemic diabetic ketoacidosis (EDKA) in a 43-year-old woman with type 2 diabetes mellitus who presented to the emergency department with problems of vomiting, cough, shortness of breath and generalised weakness after following a ketogenic diet for 2 weeks. Therapy with sodium glucose transport protein-2 empagliflozin had been started 2 months prior. Initial evaluation revealed high anion gap metabolic acidosis with blood glucose level of 169 mg/dL. Treatment for EDKA with fluid resuscitation, intravenous insulin and dextrose resolved her acidosis and symptoms in less than 24 hours. Empaglifozin was discontinued on discharge. This entity represents a diagnostic challenge since the differential diagnosis is broad with a potentially misleading clinical presentation that can result in delayed diagnosis and adverse outcomes including acute kidney injury, multiple electrolyte abnormalities, cerebral oedema, acute respiratory distress syndrome, shock and death.
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Affiliation(s)
- Azka Latif
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA.,CHI Creighton Health, Creighton University Medical Center-University Campus, Omaha, Nebraska, USA
| | - Aheli Arce Gastelum
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
| | - Akshat Sood
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
| | - Joseph Thilumala Reddy
- Internal Medicine, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, Nebraska, USA
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