Objective Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel group of oral hypoglycemic agents with multiple proven beneficial effects. However, their use has been associated with euglycemic diabetic ketoacidosis (DKA), typically triggered by risk factors such as acute illness, surgery, and decreased calorie intake. Therefore, it is recommended that patients discontinue SGLT2 inhibitors at least 24 hours before surgery to minimize this risk. We report a case of a postoperative euglycemic DKA in a patient who had discontinued SGLT2 inhibitor therapy 48 hours prior to surgery. Methods We describe the clinical course of a patient with type 2 diabetes mellitus on empagliflozin therapy who was referred for coronary artery bypass graft surgery. Results A 60-year-old man with type 2 diabetes mellitus developed euglycemic DKA a few hours after coronary artery bypass graft surgery. Laboratory results showed acute postoperative elevated anion gap metabolic acidosis with normal glucose and elevated blood ketone levels. It was later revealed that the patient was treated as an outpatient with empagliflozin; the last dose was taken 48 hours prior to his procedure. Conclusion Euglycemic DKA can occur postoperatively in patients with a history of SGLT2 inhibitor use, even 48 hours after the discontinuation of therapy. This case highlights the need to revisit the recommended time to discontinue these agents, specifically prior to major surgery, because their pharmacokinetic effects may persist after 24 hours of discontinuation, putting patients at risk for postoperative euglycemic DKA.
Lenalidomide, a synthetic derivation of thalidomide, in recent years, has been the backbone of multiple myeloma treatment leading to improved survival. Common adverse effects from lenalidomide-based regimens include hypertension, heart disease, and venous thromboembolism. Hence, thromboprophylaxis is recommended to reduce the risk of stroke. We report a case of stroke from cerebral vasculitis in a patient receiving carfilzomib, lenalidomide, and dexamethasone for relapsing multiple myeloma, not previously published. Medical oncologists should be aware of other causes of stroke among multiple myeloma patients receiving a lenalidomide-based regimen to prevent its occurrence.
OBJECTIVE To determine whether genetic risk for type 1 diabetes (T1D) differentiates the four Aβ subgroups of ketosis-prone diabetes (KPD), where A+ and A− define the presence or absence of islet autoantibodies and β+ and β− define the presence or absence of β-cell function. RESEARCH DESIGN AND METHODS We compared T1D genetic risk scores (GRSs) of patients with KPD across subgroups, race/ethnicity, β-cell function, and glycemia. RESULTS Among 426 patients with KPD (54% Hispanic, 31% African American, 11% White), rank order of GRS was A+β− > A+β+ = A−β− > A−β+. GRS of A+β− KPD was lower than that of a T1D cohort, and GRS of A−β+ KPD was higher than that of a type 2 diabetes cohort. GRS was lowest among African American patients, with a similar distribution across KPD subgroups. CONCLUSIONS T1D genetic risk delineates etiologic differences among KPD subgroups. Patients with A+β− KPD have the highest and those with A−β+ KPD the lowest GRS.
AMIODARONE-INDUCED THYROTOXICOSIS AFTER WEIGHT LOSS FOLLOWING SLEEVE GASTRECTOMY INTRODUCTION: Bariatric surgeries have shown major health benefits improvement in co-morbidities such as HTN and DM. We are less familiar with how these surgeries affect the pharmacokinetics of drugs.1,2 CLINICAL CASE: Our patient is a 65-year-old man with a fib/v tach and no prior thyroid history. He was on amiodarone 200 mg daily since September 2016. He had sleeve gastrectomy in March 2019 at weight 380 lbs. By June 2019, weight was 278 lbs. In June 2019, he had palpitations, diarrhea, and heat intolerance for one month. Labs showed: TSH <0.01 (0.4 – 4.5 MCIU/L), FT4 6.5 (0.8 – 1.8 NG/DL), and TT3 309 (76 – 181 NG/DL). Other labs: TPO antibodies <1 IU/mL (<9 IU/mL) TSI <89 (<140% baseline). Thyroid sonogram was heterogeneous without nodule He started Methimazole (MMI) 20mg BID and Prednisone 40mg daily. In the next seven weeks, symptoms and TFTs improved. FT4 was 3.1 NG/DL, TT3 was 85 NG/DL, but TSH remained <0.01 MCIU/L. Because of the rapid improvement, he was felt to have type 2 AIT (destructive thyroiditis). MMI was quickly tapered. Prednisone was tapered to 30mg daily. At week 8, he was hospitalized for septic shock from diverticulitis and perianal abscess. He also had leukopenia attributed to MMI and sepsis. MMI was stopped. Amiodarone was stopped by cardiology. TFTs during hospitalization improved on only steroids: TSH was 0.01 MCIU/ML, FT4 was 2.34 NG/DL, and TT3 was 0.56 NG/ML. He was discharged on Prednisone 30mg daily with plans to taper off steroids. CONCLUSION: Our patient is the second reported case of AIT after bariatric surgery-induced weight loss. Amiodarone is a highly lipophilic drug that accumulates in adipose tissue. Rapid weight loss may result in the release of large amounts of amiodarone into the circulation with resultant thyrotoxicosis. As clinicians, we should be aware that patients who undergo bariatric surgery are at risk for complications that are not only directly related to the operation but also related to rapid weight loss that affects how the body handles drugs. REFERENCES 1. Bourron O, Ciangura C, Bouillot J-L, Massias L, Poitou C, Oppert J-M. Amiodarone-induced hyperthyroidism during massive weight loss following gastric bypass. Obes Surg. 2007;17(11):1525–1528. http://www.ncbi.nlm.nih.gov/pubmed/18219784. Accessed September 21, 2019. 2. Geraldo M de SP, Fonseca FLA, Gouveia MR de FV, Feder D. The use of drugs in patients who have undergone bariatric surgery. Int J Gen Med. 2014;7:219–224. doi:10.2147/IJGM.S55332
With its alarmingly rising prevalence worldwide, type 2 diabetes has become a leading cause of morbidity and mortality around the planet. Efforts to prevent progression to diabetes in individuals at risk could have a significant positive public health impact. Multiple trials examining cardiovascular outcomes of Renin-Angiotensin-Aldosterone System (RAAS) inhibitors revealed, in secondary analysis, a significantly reduced risk of new onset diabetes in participants receiving these agents. This glycemic protective effect is attributed to the known implication of RAAS in the development of insulin resistance and type 2 diabetes. The DREAM trial and the NAVIGATOR trial were two large randomized controlled studies examining, as primary outcome, the effect of Ramipril and Valsartan respectively on the incidence of diabetes in patients with prediabetes. Their results confirmed a favorable glycemic effect of RAAS inhibition agents and suggested a possible added benefit of diabetes prevention to their other several cardiovascular and blood pressure benefits.
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