Euglycemic Diabetic Ketoacidosis in a Diabetic Patient Treated with SGLT2 Inhibitor

2021 ◽  
Vol 6 (1) ◽  
Author(s):  
Lavrynenko O ◽  
◽  
Santos H ◽  
Garza A ◽  
Qazi R ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Glucose Transporter ◽  
Sglt2 Inhibitor ◽  
Anion Gap ◽  
Laboratory Evaluation ◽  
Intravenous Insulin ◽  
Glucose Transporter 2 ◽  
Life Threatening ◽  
History Of

Diabetic Ketoacidosis (DKA) is a life - threatening complication and must be diagnosed and treated promptly and aggressively. The classic triad of DKA is hyperglycemia (Blood Glucose (BG) >250mg/dl; anion gap metabolic acidosis (pH <7.30 and bicarbonate <18mEq/L); and ketonemia. With Food and Drug Administration (FDA) approval of the sodium - glucose transporter 2 inhibitors (SGLT2i), DKA can occur with BG levels below 200mg/dl and has been defined as Euglycemic DKA (EuDKA). Due to the absence of hyperglycemia, the diagnosis of EuDKA is challenging and often delayed. This 60-year-old diabetic male, treated with Empagliflozin and pioglitazone, presented with diarrhea and abdominal pain, which started 20 days ago. He was admitted with dehydration and diagnosis of colitis. On admission laboratory evaluation revealed metabolic acidosis with elevated anion gap of 18mEq/L, bicarbonate of 19mEq/L, and BG of 146mg/dL. There was no history of ingestion of alcohol, salicylates, methanol, ethylene glycol and nothing to suggest lactic acidosis. The plasma creatinine was 0.79mg/dl. On the following day, he developed an increase in the anion gap to 22mEq/L and further decrease in bicarbonate to 13mEq/L, and serum ketones were detected. The patient was treated for EuDKA in ICU with intravenous insulin, dextrose (to prevent hypoglycemia), and normal saline with resolution of his symptoms and EuDKA in 3 days. With the widespread use of SGLT2i, physicians need to have a high suspicion of EuDKA in patients who present with an unexplained anion gap acidosis without or only modest elevation in BG concentration.

Case of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis

2021 ◽  
Vol 14 (8) ◽  
pp. e235953 ◽  
Author(s):  
Huei Li Yeoh ◽  
Marilyn Lee ◽  
Woei Jack Pan ◽  
Hean Yee Ong
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Insulin Infusion ◽  
Anion Gap ◽  
Subcutaneous Insulin ◽  
Intravenous Insulin ◽  
High Dependency ◽  
Sodium Glucose Cotransporter ◽  
Sliding Scale ◽  
Basal Bolus

Following non-elective orthopaedic surgery, a 61-year-old man with poorly controlled type 2 diabetes mellitus on empagliflozin developed high anion gap metabolic acidosis in the high-dependency unit. Metabolic acidosis persisted despite intravenous sodium bicarbonate, contributing to tachycardia and a run of non-sustained ventricular tachycardia. He was euglycaemic throughout hospital admission. Investigations revealed elevated urine and capillary ketones, and a diagnosis of sodium–glucose cotransporter-2 inhibitor-associated euglycaemic diabetic ketoacidosis was made. He was treated with an intravenous sliding scale insulin infusion and concurrent dextrose 5% with potassium chloride. Within 24 hours of treatment, his arterial pH, anion gap and serum bicarbonate levels normalised. After a further 12 hours, the intravenous insulin infusion was converted to a basal/bolus regimen of subcutaneous insulin, and he was transferred to the general ward. He was discharged well on subcutaneous insulin 6 days postoperatively.

Presentation of mixed diabetic ketoacidosis and metabolic acidosis due to ileal neobladder reconstruction

2021 ◽  
Vol 14 (2) ◽  
pp. e223668
Author(s):  
Dileep Kumar ◽  
Muhammad Zubair Nasim ◽  
Bilal Ahmad Shoukat ◽  
Syed Shabahat Ali Shah
Keyword(s):  
Diabetes Mellitus ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Plasma Glucose ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Anion Gap ◽  
Metabolic Complications ◽  
Ileal Neobladder ◽  
History Of

Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes mellitus. It is characterised by the biochemical triad of hyperglycaemia, ketonemia/ketonuria, and an increased anion gap metabolic acidosis. In this case, a 40-year-old male patient presented to the emergency department, with vomiting, nausea, polydipsia, polyuria and weight loss. He was found to have an elevated plasma glucose, despite having no known history of diabetes mellitus. His medical history was significant for spina bifida and ileal neobladder reconstruction. The plasma glucose level was 38 mmol/L. Blood gas analysis showed normal anion gap metabolic acidosis with high chloride and low bicarbonate. His plasma ketone level was 4.5 mmol/L. No significant reason for hyperchloraemia was identified. On initiation of DKA regimen, his condition improved and serum ketones normalised. Due to persistent hyperchloraemic metabolic acidosis, bicarbonate infusion was administered and his metabolic acidosis resolved.

scholarly journals A Case of Diabetic Ketoacidosis in a Patient on an SGLT2 Inhibitor and a Ketogenic Diet: A Critical Trio Not to Be Missed

2020 ◽  
Vol 2020 ◽  
pp. 1-3 ◽  
Author(s):  
Samantha Steinmetz-Wood ◽  
Matthew Gilbert ◽  
Katherine Menson
Keyword(s):  
Diabetic Ketoacidosis ◽  
Ketogenic Diet ◽  
Sglt2 Inhibitor ◽  
Sglt2 Inhibitors ◽  
Anion Gap ◽  
Low Carbohydrate ◽  
History Of ◽  
Ph Level ◽  
Beta Hydroxybutyrate ◽  
Euglycemic Diabetic Ketoacidosis

Results from major clinical trials have shown significant cardiorenal-protective benefits of SGLT2 inhibitors in patients with type 2 diabetes (T2DM), leading to increased popularity. A rare but serious side effect of SGLT2 inhibitors is euglycemic diabetic ketoacidosis (EDKA), which presents more covertly but has been described. Identification and report of modifiable risk factors would be an important step in helping clinicians appropriately counsel patients. In this case report, we present DKA in a patient on an SGLT2 inhibitor and ketogenic diet (KD). A 47-year-old male with a history of poorly controlled T2DM on metformin and empagliflozin presented to the emergency department (ED) with several days of pharyngitis, dyspnea, emesis, abdominal pain, and anorexia. Of note, one month prior to this event, he presented to the ED with malaise and was found to have an anion gap of 21, a bicarbonate level of 13 mmol/L, a pH level of 7.22, 3+ ketonuria, and a glucose level of 7 mmol/L (127 mg/dl). Additional workup was negative, and findings were attributed to his KD. His use of empagliflozin was not identified on his medication list. At second presentation, the patient was tachypneic and tachycardic and had mild abdominal tenderness. Labs revealed anion gap 28, bicarbonate 5 mmol/l, pH 6.94, 3+ ketonuria, glucose 14.9 mmol/L (269 mg/dl), and beta-hydroxybutyrate 8.9 mmol/L. The patient was diagnosed with DKA and was treated accordingly. With closure of anion gap, the patient was transitioned to insulin and metformin, and his empagliflozin was discontinued indefinitely. Before prescribing this medication class, physicians should inquire about low-carbohydrate diets given the higher risk for DKA, though knowledge of this risk is still not widespread.

Prolonged euglycemic diabetic ketoacidosis triggered by a single dose of sodium–glucose cotransporter 2 inhibitor

2020 ◽  
Vol 13 (10) ◽  
pp. e235969
Author(s):  
Maki Miwa ◽  
Mikio Nakajima ◽  
Richard H Kaszynski ◽  
Hideaki Goto
Keyword(s):  
Single Dose ◽  
Metabolic Acidosis ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Sglt2 Inhibitor ◽  
Glucose Levels ◽  
Intravenous Insulin ◽  
Blood Glucose Levels ◽  
Sodium Glucose Cotransporter ◽  
Euglycemic Diabetic Ketoacidosis

A 45-year-old woman was admitted for diabetic ketoacidosis (DKA). Aggressive rehydration and continuous intravenous insulin resulted in improved blood glucose levels; however, metabolic acidosis persisted. One day prior to admission, the patient took a single dose of a sodium–glucose cotransporter 2 (SGLT2) inhibitor and this likely contributed to the prolonged euglycemic DKA. A single dose of this drug remained effective for over 100 hours as evidenced by massive excretion of urine glucose continuing long after blood glucose normalisation. SGLT2 inhibitor use should be refrained in cases in which DKA has already occurred as they may result in increasing severity or prolonged DKA.

New-Onset Diabetic Ketoacidosis Secondary to Nivolumab Therapy in a Patient with Primary Central Nervous System Lymphoma

2021 ◽  
pp. 40-43
Author(s):  
Christine Feng ◽  
Pavel Kibrik ◽  
Christian Castañeda ◽  
Gurdeep Singh
Keyword(s):  
Diabetes Mellitus ◽  
Central Nervous System ◽  
Nervous System ◽  
Diabetic Ketoacidosis ◽  
Checkpoint Inhibitors ◽  
Central Nervous System Lymphoma ◽  
Anion Gap ◽  
Prior History ◽  
Life Threatening ◽  
History Of

Introduction: Inhibitors of programmed cell death receptor (PD-1) and its ligand (PD-L1), such as nivolumab and pembrolizumab, confer anti-autoimmune activities and are therefore approved for anti-cancer therapy. Their mode of action removes autoimmunity checkpoints, thus increasing the risk of immune-related adverse events. Case Presentation: This report describes a clinical case of life-threatening diabetic ketoacidosis (DKA) in a patient after long-term nivolumab administration to treat primary central nervous system lymphoma (PCNSL). The patient presented to the emergency department (ED) with symptoms of fatigue, along with nausea and vomiting for two days; laboratory testing revealed significant hyperglycemia (glucose 673 mg/dL), elevated anion gap (>27), metabolic acidosis, ketonemia, glucosuria and ketonuria, findings of which were consistent with DKA. Given no personal history of diabetes mellitus or other autoimmune conditions and additional tests ruling out alternative causes, the patient was suspected of having newly-onset DKA secondary to nivolumab treatment. Management & Outcome: The patient was treated with fluids, electrolytes replenishments and insulin drip, which closed the anion gap and normalized electrolytes. She was transitioned to subcutaneous insulin. The patient recovered well and was discharged on Metformin and longacting insulin, with close follow-up with endocrinology and oncology. Discussion: Autoimmune endocrinopathies induced by checkpoint inhibitors for cancer treatment have been reported in the past. Newly-onset hyperglycemia and DKA are common autoimmunemediated side effects of checkpoint inhibitor uses in patients without prior history of diabetes mellitus. Clinicians should be aware to prevent this potentially life-threatening condition.

scholarly journals A Case of Euglycemic Diabetic Ketoacidosis Following Canagliflozin Therapy

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A358-A358
Author(s):  
Kubra M Tuna ◽  
Randa Abdelmasih ◽  
Ramy Abdelmaseih ◽  
Mrhaf Alsamman ◽  
Joseph Robbins
Keyword(s):  
Fatty Acid ◽  
Metabolic Acidosis ◽  
Blood Glucose ◽  
Side Effects ◽  
Diabetic Ketoacidosis ◽  
Sglt2 Inhibitor ◽  
Oral Intake ◽  
Sglt2 Inhibitors ◽  
Anion Gap

Abstract Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). In general, DKA characterized by blood sugar over 250 mg/dL, anion-gap metabolic acidosis, and increased plasma or urine ketones. Approximately 2–3% of DKA patients can present with normal blood glucose levels (less than 250 mg/dl) which called euglycemic DKA. Some of the etiologies of euglycemic DKA include recent use of insulin, low caloric intake, alcoholism, chronic liver disease, and pregnancy. Very rarely, SGLT2 inhibitor use may be responsible for euglycemic DKA. Case Presentation: Here we present a case of 44 years old female with a past medical history of DM type 2 who presented with acute onset of nausea and vomiting. Initial laboratory findings were remarkable for anion gap metabolic acidosis with a blood glucose level of 201 mg/dl. The patient was on long-acting insulin along with Canagliflozin and Metformin therapy over years and reported being compliant with medications. She was treated with intravenous insulin therapy which resolved acidosis as well as symptoms. The patient was discharged with recommendations of discontinuation of Canagliflozin. Discussion: SGLT2 inhibitors are the novel class of oral antidiabetic drugs which widely used due to their favorable cardiovascular and renal outcomes independent of glycemic control. However, their side effects remain a concern. DKA is a rare but serious side effect of SGLT2 inhibitors with an incidence rate of 9.4% in type 1 DM and less than 0.2% in type 2 DM. Patients typically present with euglycemia or low-grade hyperglycemia which results in a diagnostic challenge for treating physicians. SGLT2 inhibitors increase urinary glucose excretion with a subsequent decrease in circulating insulin and an increase in glucagon, rendering a metabolic shift from glucose to fatty acid utilization. During times of intercurrent illness (decreased oral intake, sepsis) or metabolic stress (surgery), decreased carbohydrate intake coupled with the aforementioned changes will result in decreased insulin secretion and increased counter-regulatory hormones including adrenaline and cortisol, promoting lipolysis, fatty acid oxidation, and ketone production by the liver which ultimately leading to euglycemic DKA. Conclusion: SGLT2 inhibitors induced euglycemic DKA treatment is identical to classic DKA with consideration of the lack of hyperglycemia. Appropriate patient counseling to ensure safe SGLT2 inhibitor therapy is crucial, including appropriate holding parameters during concomitant volume-depleting illnesses and decreased oral intake. Timely diagnosis of euglycemic DKA, and recognitions of other rare but lethal side effects to decrease overall morbidity and mortality.

scholarly journals COVID-19 Infection with Refractory Diabetic Ketoacidosis- A case Report

2021 ◽  
Vol 7 (2) ◽  
pp. 54-56
Author(s):  
Reshmi Mishra ◽  
◽  
Jyoti Ranjan Behera ◽  
P. Ramkumar ◽  
Mukesh Kumar Jain ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 1 Diabetes ◽  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Vital Organ ◽  
Increased Risk ◽  
Life Threatening ◽  
Life Threatening Complication ◽  
New Onset

Diabetic ketoacidosis is an acute life-threatening complication of type 1 diabetes. Sometimes it is the first presentation in an undiagnosed child. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) and diabetes mellitus are very much interrelated as diabetes mellitus is associated with an increased risk of severe COVID19 at the same time, many cases of new-onset diabetes had been diagnosed. Hyperglycemia, metabolic acidosis, and ketonemia are classical presentations. It is essential to correct the acidosis and fluid correction and insulin therapy in these patients, leading to vital organ dysfunction. In refractory metabolic acidosis, renal replacement therapy may help

scholarly journals d-Lactate: A Novel Contributor to Metabolic Acidosis and High Anion Gap in Diabetic Ketoacidosis

2013 ◽  
Vol 59 (9) ◽  
pp. 1406-1407 ◽  
Author(s):  
Jinshuang Bo ◽  
Wei Li ◽  
Zengqiang Chen ◽  
Daniel G Wadden ◽  
Edward Randell ◽  
...  
Keyword(s):  
Metabolic Acidosis ◽  
Diabetic Ketoacidosis ◽  
Anion Gap
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