Periprocedural Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter 2 Inhibitor Therapy During Colonoscopy

Comment on Hamblin et al. Capillary Ketone Concentrations at the Time of Colonoscopy: A Cross-Sectional Study With Implications for SGLT2 Inhibitor–Treated Type 2 Diabetes. Diabetes Care 2021;44:e124–e126

“…We have suggested that this threshold should prompt acid-base analysis in those who have not sufficiently withheld their SGLT2i and insulin dextrose infusions if required, not automatic cancellation of colonoscopy. We agree that colonoscopies are low-risk procedures that can be safely undertaken unless the BHB values are close to the diabetic ketoacidosis (DKA) threshold, i.e., 3.0 mmol/L, as evident from our case series (2). Applying a cutoff of 1.0 mmol/L, we observed an 18% (14 of 77) incidence of hyperketonemia among SGLT2i-treated patients.…”

“…Conversely, although a low BHB threshold comes with the burden of identifying benign ketosis, ketoacidosis is unlikely to be missed with this strategy. This was evident in our EDKA series, where patient number 1 presented with a BHB of 1.6 mmol/L (below the 1.7 mmol/L cutoff) before colonoscopy, increasing to 2.0 mmol/L postprocedure, reiterating the significance of a postcolonoscopy measurement (2).…”

Response to Comment on Hamblin et al. Capillary Ketone Concentrations at the Time of Colonoscopy: A Cross-Sectional Study With Implications for SGLT2 Inhibitor–Treated Type 2 Diabetes. Diabetes Care 2021;44:e124–e126

“…Regarding the authors' previous publication (5), we note that ketone concentrations ranged from 2.9 to 5.2 mmol/L in all three of their reported SGLT2i-treated colonoscopy cases in which the biochemistry completely supported the diagnostic criteria of DKA (pH #7.30 and bicarbonate #18 mEq/L) (6), well above the upper limit of 1.7 mmol/L for the normal reference range defined in our article.…”

Body mass index is inversely associated with capillary ketones at the time of colonoscopy: Implications for SGLT2i use

“…It is therefore not surprising that increasing numbers of people undergoing a colonoscopy are taking SGLT2i, and this will likely increase, given their benefits in cardiac failure and renal disease irrespective of diabetes 10–13 . People with diabetes are at increased risk of SGLT2i‐associated diabetic ketoacidosis (DKA) 14–16 and there have been case reports of DKA associated with colonoscopy and SGLT2i‐treated diabetes 17 . It is not currently known if people treated with SGLT2i who do not have diabetes are also at risk.…”