COVID-19-associated euglycemic diabetic ketoacidosis in a patient with type 2 diabetes on SGLT2 inhibitor: a case report

Abstract

Type 2 diabetes mellitus (DM) patients are at high risk for the development of severe COVID-19. Euglycemic diabetic ketoacidosis (eu-DKA) is a rare life-threatening complication associated with the use of SGLT2 inhibitor that may be unnoticed, particularly in a pandemic setting, due to the absence of significant hyperglycemia, delaying its treatment. In this report, we describe a case of a 56-year-old patient who presented an elevated anion gap metabolic acidosis during a SARS-CoV-2 infection and was diagnosed with SGLT2-associated euglycemic diabetic ketoacidosis. COVID-19 may increase patients’ insulin demand, present gastrointestinal symptoms, and increase the production of ketone bodies. This situation can be worsened in susceptible diabetic patients on SLGT2 inhibitors, due to the persistent glycosuria, which can cause volume depletion. Recently some authors recommended that insulin-deficient patients or those using SGLT2 inhibitors should monitor for ketosis using available home testing kits in case of infections and should discontinue the medication in case of COVID-19. Given the increased use of this drug class in the management of type 2 DM patients due to its reduction of cardiovascular risk, we set out to emphasize the importance for the medical community to consider the possibility of eu-DKA on SARS-CoV-2-infected patients using SLGT2 inhibitors, so physicians can provide these patients with appropriate therapy promptly.

A Case of Euglycemic Diabetic Ketoacidosis in a Patient With Type 2 Diabetes Mellitus and COVID-19

“…To our knowledge, this is the only case of a patient with a medical history of T2DM treated with an SGLT2 inhibitor, a COVID-19 diagnosis, severe acidemia (pH ≤ 7.1), negative imaging, and no signs of respiratory compromise [7][8][9][10][11]. In this patient, it is proposed that the severe acidemia (pH = 7.06) was exacerbated by his active COVID-19 infection, causing eu-DKA.…”

“…This case did not report a measured serum pH [ 7 ]. In the second case, the patient had a history of T2DM, showed signs of COVID-19 pneumonia on imaging, had decreased oxygen saturation on room air, required high flow nasal cannula for eight days, and displayed moderate acidemia in the ICU (pH = 7.28) [ 8 ]. The third case had a patient with a history of T2DM who also showed signs of COVID-19 pneumonia on imaging, resulting hypoxemic respiratory failure with intubation, and moderate acidemia (pH = 7.24) [ 9 ].…”

Sodium-glucose co-transporter 2 inhibitors in COVID-19: meeting at the crossroads between heart, diabetes and infectious diseases

“…In another case series, Chamorro-Pareja et al [19] reported that the majority of people presenting with DKA and COVID-19 had T2D and not T1D and contrary to expectation, they experienced good glycemic control before admission. Taking into account the growing number of reports describing patients who presented with euglycemic DKA in the context of COVID-19 and SGLT2i use [20], there is a need for increased vigilance by physicians to properly recognize and treat such cases. The data suggest that SARS-CoV-2 might potentially exert direct diabetogenic effects by attacking beta-cells and significantly impairing insulin secretion, and in conjunction with the exacerbation of insulin resistance due to systemic inflammation, finally leads to relative insulinopenia and the development of DKA [18][19][20].…”

“…Taking into account the growing number of reports describing patients who presented with euglycemic DKA in the context of COVID-19 and SGLT2i use [20], there is a need for increased vigilance by physicians to properly recognize and treat such cases. The data suggest that SARS-CoV-2 might potentially exert direct diabetogenic effects by attacking beta-cells and significantly impairing insulin secretion, and in conjunction with the exacerbation of insulin resistance due to systemic inflammation, finally leads to relative insulinopenia and the development of DKA [18][19][20]. Further studies are needed to clarify to what extent co-administration with insulin might alleviate the risk of DKA in people with COVID-19 and T2D receiving SGLT2i.…”

The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?

“…If patients requiring hospitalization for Covid-19 continue on SGLT2i, they should be monitored for DKA, which can occur in patients with Covid-19 independently of treatment, but can sometimes also be associated with SGLT2i use [ 66 ]–[ 68 , 108 ]–[ 116 ]. For patients with Covid-19 who are not hospitalized, we suggest that factors that may increase the risk for DKA are considered, namely fluid loss due to diarrhoea or low intake of food and drink due to a suppressed appetite or gastrointestinal symptoms.…”