Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series

Henrique A Puls; Nathan L Haas; Brian J Franklin; Nik Theyyunni; Carrie E Harvey

doi:10.1016/j.ajem.2021.01.033

Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series

Am J Emerg Med. 2021 Jun:44:11-13. doi: 10.1016/j.ajem.2021.01.033. Epub 2021 Jan 24.

Authors

Henrique A Puls¹, Nathan L Haas², Brian J Franklin³, Nik Theyyunni⁴, Carrie E Harvey⁵

Affiliations

¹ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. Electronic address: hapuls@med.umich.edu.
² Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA.
³ University of Michigan Medical School, Ann Arbor, MI, USA.
⁴ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA.
⁵ Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA.

PMID: 33571749
DOI: 10.1016/j.ajem.2021.01.033

Abstract

Introduction: Euglycemic diabetic ketoacidosis (EuDKA) associated with Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use has been described but remains poorly understood. Data on Emergency Department (ED) presentation, resource utilization, and safety outcomes for these patients are lacking. We report a case series of patients diagnosed with EuDKA in the ED.

Methods: An electronic medical record search identified adult patients presenting to a large tertiary ED with EuDKA. They were screened for concurrent use of SGLT2i. Clinical presentation, resource utilization, safety, and disposition data were collected and described.

Results: Five patients were included for analysis. Median age [range] was 57 [43-73] years. Presenting symptoms included nausea, vomiting, fatigue, and altered mental status. Initial results included: serum glucose 191 mg/dL [176-215], venous pH 7.01 [6.95-7.30], serum HCO3 8 mEq/L [6-13], anion gap 27 [26-31], serum beta-hydroxybutyrate 9.9 mmol/L [9.2-12.3], and urine ketones 150 [150-150]. Patients remained on an insulin infusion for 18.77 h [11.25-56.48]. There were zero episodes of hypoglycemia and one episode of hypokalemia while on insulin infusion. Time to resolution of metabolic acidosis was 23.82 h [15.45-24.77].

Discussion: We report a case series of ED patients with EuDKA associated with SGLT2i use, and describe presentation characteristics, resource utilization, and safety outcomes. Emergency physicians should be aware of the association between SGLT2i use and EuDKA. An appropriate work-up should be pursued for patients taking an SGLT2i who present with symptoms suggestive of DKA, including nausea, vomiting, malaise, and altered mental status, or are noted to have an unexplained elevated anion gap metabolic acidosis.

Keywords: Acid-Base imbalance; Diabetes complications; Diabetic ketoacidosis; Insulin; Sodium-glucose transporter 2.

MeSH terms

Adult
Aged
Diabetic Ketoacidosis / chemically induced*
Diabetic Ketoacidosis / drug therapy
Emergency Service, Hospital
Female
Humans
Hypoglycemic Agents / administration & dosage
Insulin / administration & dosage
Male
Middle Aged
Sodium-Glucose Transporter 2 Inhibitors / adverse effects*

Substances

Hypoglycemic Agents
Insulin
Sodium-Glucose Transporter 2 Inhibitors