Letter to the Editor: Response to Hamblin et al body mass index is inversely associated with capillary ketones at the time of colonoscopy: Implications for SGLT2i use

Umapathysivam, Mahesh M.; Inglis, Joshua M.; Meyer, Emily J.; Thiruvenkatarajan, Venkatesan; Jesudason, David

doi:10.1111/cen.14707

Cited by 3 publications

(3 citation statements)

References 2 publications

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“…Ongoing research can elucidate the frequency and degree of ketosis within these patients as SGLT2i usage increases. 28 Our results in an adult cohort contrast to paediatric studies. Levy and Waltzmann's assessment of 188 patients younger than 6 years of age with dehydration and gastroenteritis found a median serum BHB of 3.1 mmol/L (IQR 1.2-4.6).…”

Section: Discussioncontrasting

confidence: 69%

Clinical significance of an elevated on‐admission beta‐hydroxybutyrate in acutely ill adult patients without diabetes

Lin,

Depczynski,

Varndell

et al. 2024

Emerg Medicine Australasia

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ObjectiveTo determine the relationship between point‐of‐care β‐hydroxybutyrate (BHB) concentration and outcomes in adult patients without diabetes admitted through ED.MethodsThis was a prospective study from 10 March to 2 July 2021. Admitted patients without diabetes had capillary BHB sampled in ED. Outcomes of length‐of‐stay (LOS), composite mortality/ICU admission rates and clinical severity scores (Quick Sepsis Organ Failure Assessment score/National Early Warning Score [qSOFA/NEWS]) were measured. BHB was assessed as a continuous variable and between those with BHB above and equal to 1.0 mmol/L and those below 1.0 mmol/L.ResultsA total of 311 patients were included from 2377 admissions. Median length‐of‐stay was 4.1 days (IQR 2.1–9.8), 18 (5.8%) died and 37 (11.8%) were admitted to ICU. Median BHB was 0.2 mmol/L (IQR 0.1–0.4). Twenty‐five patients had BHB ≥1.0 mmol/L and five were >3.0 mmol/L. There was no significant difference in median LOS for patients with BHB ≥1.0 mmol/L compared to non‐ketotic patients, 5.3 days (IQR 2.2–7.5) versus 4.1 days, respectively (IQR 2.0–9.8) (P = 0.69). BHB did not correlate with LOS (Spearman ρ = 0.116, 95% confidence interval: 0.006–0.223). qSOFA and NEWS also did not differ between these cohorts. For those 25 patients with BHB ≥1.0 mmol/L, an infective/inflammatory diagnosis was present in 11 (44%), at least 2 days of fasting in 10 (40%) and ethanol intake >40 g within 48 h in 4 (16%).ConclusionsRoutine BHB measurement in patients without diabetes does not add to clinical bedside assessment and use should be limited to when required to confirm a clinical impression.

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Section: Discussioncontrasting

confidence: 69%

Clinical significance of an elevated on‐admission beta‐hydroxybutyrate in acutely ill adult patients without diabetes

Lin,

Depczynski,

Varndell

et al. 2024

Emerg Medicine Australasia

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“…The observation that individuals without diabetes can develop SGLT2i-associated ketoacidosis has significant implications for the management of these patients in high-risk ketogenic situations. Fasting periods for surgery, colonoscopy, or hospitalization have been identified as high-risk times for SGLT2i-associated ketoacidosis ( 6 , 7 , 16 ). In individuals with diabetes, guidelines suggest that SGLT2i should not be administered for 3 days prior to high-risk situations (e.g., surgery or colonoscopy); however, SGLT2i should be continued if an individual does not have diabetes ( 12 ).…”

Section: Discussionmentioning

confidence: 99%

“…Importantly, the phenomenon of ketoacidosis was not appreciated in the initial randomized controlled trials of SGLT2i therapy in diabetes ( 4 , 5 ). The initial indication of the phenomenon was identified via case reports on off-label use of SGLT2i in type 1 diabetes and later on-label use in type 2 diabetes ( 2 , 3 , 6 – 8 ).…”

Section: Introductionmentioning

confidence: 99%

Euglycemic Ketoacidosis in Two Patients Without Diabetes After Introduction of Sodium–Glucose Cotransporter 2 Inhibitor for Heart Failure With Reduced Ejection Fraction

Umapathysivam,

Gunton,

Stranks

et al. 2023

Diabetes Care

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OBJECTIVE Ketoacidosis induced by sodium–glucose cotransporter 2 inhibitor (SGLT2i) treatment has been consistently observed in clinical practice in patients with type 2 diabetes despite minimal indication from the landmark cardiovascular outcome trials. It has been postulated that individuals without diabetes will not develop this complication due to an adequate insulin secretory capacity, which will protect against significant ketone formation. Cardiovascular outcome trials examining SGLT2i use in individuals with heart failure but not diabetes have not reported ketoacidosis. RESEARCH DESIGN AND METHODS We describe the first two case reports of severe nondiabetic ketoacidosis after initiation of an SGLT2i for the treatment of heart failure with reduced ejection fraction, and we describe the management strategies employed and implication for the pathophysiology of SGLT2i-associated ketoacidosis. RESULTS Each individual presented with ketoacidosis triggered by reduced oral nutrition intake. For both individuals, ketoacidosis resolved with intravenous glucose administration, encouragement of consumption of oral glucose-containing fluid, and minimal insulin administration. CONCLUSIONS These two cases demonstrate that SGLT2i-associated ketoacidosis is possible in individuals without diabetes.

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Peri-colonoscopy Implications of Sodium-Glucose Cotransporter-2 Inhibitor Therapy: A Mini-review of Available Evidence

Thiruvenkatarajan¹,

Inglis²,

Meyer³

et al. 2023

Canadian Journal of Diabetes

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Letter to the Editor: Response to Hamblin et al body mass index is inversely associated with capillary ketones at the time of colonoscopy: Implications for SGLT2i use

Cited by 3 publications

References 2 publications

Clinical significance of an elevated on‐admission beta‐hydroxybutyrate in acutely ill adult patients without diabetes

Clinical significance of an elevated on‐admission beta‐hydroxybutyrate in acutely ill adult patients without diabetes

Euglycemic Ketoacidosis in Two Patients Without Diabetes After Introduction of Sodium–Glucose Cotransporter 2 Inhibitor for Heart Failure With Reduced Ejection Fraction

Peri-colonoscopy Implications of Sodium-Glucose Cotransporter-2 Inhibitor Therapy: A Mini-review of Available Evidence

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