Sodium-Glucose Co-transporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Bariatric Surgery: A Case and Literature Review

Abstract

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce cardiovascular, kidney, and overall mortality. SGLT2i are also associated with a rare adverse event, euglycemic diabetic ketoacidosis (EDKA). This report describes a case of EDKA one day after bariatric surgery in a 51-year-old female with type 2 diabetes mellitus managed with the SGLT2i, canagliflozin. She was following a ketogenic diet for three weeks prior to surgery. The patient made a steady recovery with rapid anion gap closure followed by prolonged non-anion gap metabolic acidosis. Her medical record was tagged with a life-threatening reaction to SGLT2i. The risk of EDKA from SGLT2i may be increased by a low carbohydrate diet or postoperative status. Our case was complicated by hypokalemia, exemplifying the need for aggressive electrolyte management. Further guidance is needed to manage risk factors provoking EDKA and the use of SGLT2i therapy after an episode of EDKA.

Diabetes and Cancer: Risk, Challenges, Management and Outcomes

“…Sodium glucose transporter-2 (SGLT-2) inhibitors may also be used, however patients on SGLT-2 inhibitors should be monitored closely for urinary tract infection and candiadiasis. In addition, there are reports of euglycemic diabetic ketoacidosis related to SGLT-2 inhibitors [127]. Glucagon like peptide (GLP)-1 agonists that are available in oral and injection forms are another option, however their gastrointestinal side effects and weight loss can be troublesome in cancer patients.…”

New Diabetic Medication Sodium-Glucose Cotransporter-2 Inhibitors Can Induce Euglycemic Ketoacidosis and Mimic Surgical Diseases: A Case Report and Review of Literature

“…The onset of EDKA was recognized between POD 0 [withhold of SGLT2-I for 48 h prior to surgery ( 38 )] and 6 weeks after [under SGLT2-I intake ( 1 )] surgery, hence, reflecting a wide range of clinical presentation. Reported patients were between 42 ( 31 ) and 76 ( 2 ) years of age, were prescribed empagliflozin ( 2 , 33 , 37 – 45 , 47 – 50 , 55 ), ertugliflozin ( 53 ), canagliflozin ( 2 , 31 – 33 , 35 , 36 , 49 , 54 ), or dapagliflozin ( 1 , 27 , 35 , 41 , 46 , 51 , 54 ), and female gender was an assumed risk factor ( 56 ). A long history of diabetes duration (>10 years) and the use of oral antidiabetics with or without insulin application were reported as predisposing patients' characteristics ( 57 ).…”

Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

“…However, not all patients who are on SGLT2 inhibitors might develop euglycemic DKA. Other risk factors for developing euglycemic DKA include recent use of insulin, pregnancy, heavy alcohol consumption, chronic liver disease, glycogen storage disease, and decreased calorie intake [ 2 , 3 ]. Empagliflozin may reach a peak plasma concentration 1.33–3.0 hours after administering the drug and the pharmacological effects may persist for more than 10 days which is evident by the existence of glucosuria after 10 days of stopping the drug [ 6 , 7 ].…”

“…It is viable to either restart SGLT2 inhibitors after euglycemic DKA or prescribe other antidiabetic medications [ 4 ]. Most cases in the literature discontinue SGLT2 inhibitors indefinitely after an episode of SGLT2 induces EDKA, although there is no clear guideline on whether it is best to discontinue or continue on using SGLT inhibitors [ 1 , 2 , 12 , 15 ]. Our patient was restarted on another SGLT2 inhibitor, canagliflozin, and did not develop a recurrence of EDKA.…”

“…Other factors that are encountered in the in-patient setting are sepsis, major surgeries, and cerebrovascular events. Pregnancy may also cause EDKA as it is a state of physiological hypoinsulinemia [2][3][4]. e prognosis is usually excellent if the condition is recognized early and treated appropriately [4].…”