scholarly journals Euglycemic diabetic ketoacidosis in type 2-diabetes mellitus treated with SGLT2 inhibitors - a report on two cases

2019 ◽  
Author(s):  
Antonio Burgio ◽  
Maurizio Alletto ◽  
Salvatore Amico ◽  
Umberto Castiglione ◽  
Giovanni Fulco ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Diabetic Ketoacidosis ◽  
Correct Diagnosis ◽  
Gas Analysis ◽  
Sglt2 Inhibitors ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Heavy Alcohol Consumption ◽  
Life Threatening

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new second-line medication in themanagement of hyperglycemia in type 2 diabetes. These drugs can be associated with thedevelopment of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucoselevels. This is a life-threatening clinical condition termed euglycemic DKA, of which the diagnosiscan be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes whopresented to the Emergency Department with malaise, nausea and vomiting. Both patients had beentaking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis,namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysisshowed severe metabolic acidosis with increased anion gap, positive serum and urine ketones andnormal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids,insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovereduneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterialblood gas analysis and serum ketones should lead to correct diagnosis of euDKA.

scholarly journals Euglycemic diabetic ketoacidosis in type 2-diabetes mellitus treated with SGLT2 inhibitors - a report on two cases

2019 ◽  
Author(s):  
Antonio Burgio ◽  
Maurizio Alletto ◽  
Salvatore Amico ◽  
Umberto Castiglione ◽  
Giovanni Fulco ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Diabetic Ketoacidosis ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Sglt2 Inhibitors ◽  
Blood Gas ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Arterial Blood Gas Analysis

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new second-line medication in the management of hyperglycemia in type 2 diabetes. These drugs can be associated with the development of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucose levels. This is a life-threatening clinical condition termed euglycemic DKA, of which the diagnosis can be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes who presented to the Emergency Department with malaise, nausea and vomiting. Both patients had been taking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis, namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysis showed severe metabolic acidosis with increased anion gap, positive serum and urine ketones and normal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids, insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovered uneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterial blood gas analysis and serum ketones should lead to correct diagnosis of euDKA.

scholarly journals Euglycemic diabetic ketoacidosis in type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitors. A report on two cases

2018 ◽  
Vol 13 (1) ◽  
pp. 54-58 ◽  
Author(s):  
Antonio Burgio ◽  
Maurizio Alletto ◽  
Salvatore Amico ◽  
Umberto Castiglione ◽  
Giovanni Fulco ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Diabetic Ketoacidosis ◽  
Blood Gas Analysis ◽  
Gas Analysis ◽  
Blood Gas ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Sodium Glucose Cotransporter ◽  
Arterial Blood Gas Analysis

Sodium-glucose cotransporter 2 inhibitors are a new second-line medication in the management of hyperglycemia in type 2 diabetes. These drugs can be associated with the development of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucose levels. This is a life-threatening clinical condition termed euglycemic DKA (euDKA), of which the diagnosis can be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes who presented to the Emergency Department with malaise, nausea and vomiting. Both patients had been taking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis, namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysis showed severe metabolic acidosis with increased anion gap, positive serum and urine ketones and normal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids, insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovered uneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterial blood gas analysis and serum ketones should lead to correct diagnosis of euDKA.

scholarly journals Evaluation of liver function in acute complications of type 2 diabetes mellitus

2019 ◽  
Vol 6 (1) ◽  
pp. 118
Author(s):  
Periyasamy Sivakumar ◽  
Thiyagarajan Manjuladevi Moonishaa ◽  
Neethu George ◽  
Reena Savariraj
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Liver Function ◽  
Arterial Blood Gas ◽  
Arterial Blood ◽  
Elevated Liver Enzymes ◽  
Acute Complications

Background: Diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic state (HHS) are the acute complications of Type 2 Diabetes Mellitus (T2DM). The aim was to evaluate the role of liver function parameters in T2DM patients with DKA and HHS.Methods: This descriptive study included 50 subjects in each of the following four groups: non-T2DM, T2DM without acute complications, T2DM with DKA, T2DM with HHS. Data on demography, clinical and lab diagnosis, as well as liver function parameters were collected from May 2017 to October 2017. The baseline data and liver function parameters were compared across the study groups.Results: There was significant hyperglycemia and associated baseline electrolyte, Arterial Blood Gas (ABG) analysis changes in acute complications of T2DM. Besides GGT, the serum total and direct bilirubin levels were also higher in T2DM cases with DKA. Significant levels of hypoalbuminemia and hyperglobulinemia along with raised SGPT and ALP levels were seen in acute complications of T2DM, especially in HHS complicating T2DM.Conclusions: Decreased serum albumin levels, along with elevated liver enzymes-SGPT, ALP, and GGT characterized the acute complications of T2DM, with specific alterations of liver function parameters seen in DKA and HHS cases.

scholarly journals Euglycemic Diabetic Ketoacidosis Secondary to SGLT2-inhibitor Use in Combination With a Ketogenic Diet

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A380-A381
Author(s):  
Joi C Hester ◽  
Stacy Zimmerman ◽  
Teresa Allison Nimmo ◽  
Wesley Cunningham ◽  
Joshua Liu ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Blood Glucose ◽  
Diabetic Ketoacidosis ◽  
Ketogenic Diet ◽  
Sglt2 Inhibitor ◽  
Perioperative Period ◽  
Anion Gap ◽  
Arterial Blood ◽  
Euglycemic Diabetic Ketoacidosis

Abstract Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are cardiorenal protective agents increasingly used in patients with diabetes. Cases of euglycemic diabetic ketoacidosis (euDKA) have been reported particularly among patients with type 1 diabetes. Our case is an example that highlights the role SGLT-2 inhibitors play in the development of euDKA in a patient with type 2 diabetes with confounding factors of strict adherence to a ketogenic diet and ankle fracture. A 72-year-old female with a history of type 2 diabetes presented to the emergency department (ED) with right ankle pain and obvious deformity after a mechanical fall. Radiography of the right lower extremity confirmed distal fracture of the tibia and fibula. After reduction of her fracture in the ED, she was admitted in anticipation of an open reduction internal fixation. Her diabetes was controlled on empagliflozin monotherapy and adhering to a ketogenic diet. She monitored her blood ketones daily at home and reported values in the 3–4 mmol/L range. On admission, her basic metabolic panel (BMP) revealed a blood glucose of 148 mg/dL, bicarbonate of 20 mEq/L, anion gap of 18 mEq/L, Cr of 1.3 mg/dl, and eGFR of 40 mL/min. Her beta-hydroxybutyrate (BHB) was 5.09 mmol/L. The initial assessment was presumed starvation ketosis. On hospital day three, she complained of continued nausea, polydipsia, and abdominal pain. Chart review revealed nocturia with approximately 3–4 voids per night. Repeat BMP showed a blood glucose of 152 mg/dL, bicarbonate of 16 mEq/L, anion gap still at 18 mEq/L, Cr 1.4 mg/dl, and eGFR of 37 mL/min. Since admission, all of her blood glucose levels ranged between 118–178 mg/dL. She denied dyspnea but exhibited Kussmaul respirations on physical exam. Repeat labs revealed a BHB of 8.92 mmol/L, and arterial blood gas (ABG) showed pH 7.2, pCO2 23, pO2 100, bicarbonate 8.6 mEq/L, consistent with high-anion gap metabolic acidosis, confirming the diagnosis of euDKA. Her empagliflozin had been held since admission, but she had not received any insulin up to this point due to euglycemia. She was immediately started on a weight-based dose of 12 units of insulin glargine with subsequent improvement of her BHB and anion gap. This patient’s use of an SGLT2-inhibitor in combination with her being on a ketogenic diet, contributed to a nonregulated state of ketone production leading to euDKA in the perioperative period. As SGLT2-inhibitors become more readily available, it is important to educate physicians and patients about the risk of euDKA during fasting, ketogenic diets, and the perioperative period.

scholarly journals SAT-LB118 Euglycemic Diabetic Ketoacidosis in Type 2 Diabetes Mellitus

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Kevin A Arao ◽  
Harikrashna Bhatt ◽  
Christina M Capistrano ◽  
Hui Zhang ◽  
Christopher Cosgrove
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Diabetic Ketoacidosis ◽  
Caloric Intake ◽  
Anion Gap ◽  
Medical Emergency ◽  
Diagnostic Challenge ◽  
Arterial Blood

Abstract Introduction Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes. It is characterized by the triad of hyperglycemia (>250mg/dL), high anion gap metabolic acidosis (HAGMA), and ketonemia. Rarely, it would present with normal or mildly increased glucose levels (<200mg/dL) making it a diagnostic challenge. We present a case of euglycemic DKA in type 2 diabetes mellitus (T2DM). Case Presentation A 77-year-old woman living in a nursing home with a history of T2DM treated with insulin glargine, but for the past three days refused medications with decreased caloric intake. There were no new medications or ingestion of alcohol or toxic substances. She then developed worsening altered mental status hence admission to the hospital. Her vital signs were within normal limits. Physical examination revealed no abdominal tenderness. Initial laboratory studies showed glucose 83 mg/dL, bicarbonate 10 mmol/L, and anion gap 23 meq/L. Urinalysis significant with trace ketones. The following day, further work-up was done remarkable with beta-hydroxybutyrate 8.3 mmol/L, lactic acid 0.8 mmol/L, and toxicology panel negative. Arterial blood gas showed pH 7.137, pCO2 14 mmHg, and bicarbonate 4.8 mmol/L. DKA protocol was initiated and she was treated with insulin drip, bicarbonate drip, and intravenous fluid administration with D5W. After two days, DKA resolved and was subsequently transitioned to subcutaneous insulin. Discussion Similar to the findings of Burge et al, our case showed that decreased caloric intake predisposes patients with diabetes mellitus to euglycemic DKA during periods of insulin deficiency. A proposed mechanism for the accelerated ketosis is due to the effects of elevated levels of glucagon or catecholamines on lipolysis. Other causes of euglycemic DKA include pregnancy, heavy alcohol use, SGLT2 inhibitors, cocaine abuse, pancreatitis, sepsis, and chronic liver disease. It is also important to rule out other causes of HAGMA. In our case, although she has decreased caloric intake, starvation ketoacidosis usually leads to serum bicarbonate levels >18mmol/L. Management is similar to DKA but important difference is the dextrose administration to prevent hypoglycemia. Conclusion Euglycemic DKA is a medical emergency that may be overlooked as patients present without marked hyperglycemia. Physicians should have a high suspicion as this may result in delayed management and potential adverse metabolic consequences.

scholarly journals Incidence of Diabetic Ketoacidosis in Hospitalized COVID19 Patients With Type 2 Diabetes

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A346-A347
Author(s):  
Wael Mohammad Almistehi ◽  
Abdulrahman Mohammed Alturki ◽  
Bashear Adnan Bukhari
Keyword(s):  
Type 2 Diabetes ◽  
Saudi Arabia ◽  
Mortality Rate ◽  
Diabetic Ketoacidosis ◽  
Care Center ◽  
Tertiary Care ◽  
Tertiary Care Center ◽  
Life Threatening ◽  
Life Threatening Complication

Abstract Introduction: Diabetes is a disease of persistent hyperglycemia with a devastating complication and even death if left untreated. Morbidity and mortality often increased for any condition among patients with diabetes. Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes. It can occur to type 2 diabetes (T2DM) under severe stress. Since the pandemic of Coronavirus disease 2019 (COVID19), that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, Hubei China, in December 2019, more than 47 million infected cases reported leading to more than 1.2 million deaths reported worldwide. The presence of diabetes in COVID19 patients had a higher odd of severity and mortality of the COVID19 compared to patients without diabetes. Our study aims to identify the incidence rate of DKA in T2DM admitted with COVID19 in a tertiary care center. Evidence showed those populations at considerable risk for morbidity and mortality and no available data in Saudi Arabia. Method: A retrospective cohort of adult patients admitted for COVID19, with a diagnosis of T2DM or clinical evidence of DKA in a tertiary care center named King Fahad Medical City located in Riyadh in Saudi Arabia. The study involved a chart review. Data collected from the beginning of March 2020 till the end of June 2020. Results: Of 244 patients with T2DM admitted for COVID19, 190 patients were male, and 55 patients were female. The mean age was 59-year-old. out of 244 patients collected, 20 had developed DKA. The incidence rate of DKA was 8%. Number and percentage of male was 15 (71.4%) and female 6 (28.6%). Out of 20 patients admitted with DKA and COVID-19, two patients were not known to have diabetes prior to the presentation. Mortality resulted in 5 out of 20 during admission stay, represent 25% of all patients with DKA. Discussion: Here we report the first study in S.A. about DKA incidence in T2DM with COVID19 pneumonia. In the present study, an alarming observation of a higher incidence of DKA in a patient with type 2 diabetes and COVID19 infection as incidence reaches 8% over a short period of time while incidence worldwide area range was less than 2 per 1000 person-year for DKA in type 2 diabetes without COVID19. A study reported 20 % of patients who have diabetes and COVID19 presented ketosis developed DKA. We report the incidence of DKA in selected group. The mortality rate was not far from different evidence in the world. The mortality rate was 25% in the present study. In the USA, it reaches 30% of inpatient with hyperglycemia at presentation. Conclusion: DKA is a life-threatening complication, and it became worse when it is related to COVID19. The incidence of DKA and mortality related to COVID19 increased when DKA occurs for T2DM subjects. A more prospective study is warranted and a longer duration of the study to establish the accurate incidence and mortality rate.

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