When Guidelines Fail: Euglycemic Diabetic Ketoacidosis After Bariatric Surgery in a Patient Taking a Sodium–Glucose Cotransporter-2 Inhibitor: A Case Report

Abstract

A 42-year-old woman with diabetes mellitus type 2 treated with the sodium-glucose cotransporter-2 inhibitor canagliflozin underwent elective bariatric gastric bypass. The canagliflozin was held for 24 hours preoperatively. She physiologically decompensated on postoperative day 2. Ultimately, she was diagnosed with euglycemic diabetic ketoacidosis that required intensive care management. This diagnosis was challenging to make as the patient never became hyperglycemic. We use this case to discuss the pharmacology and potential risk of perioperative sodium glucose cotransporter-2 inhibitor administration and to advocate for revision of current guidelines regarding the perioperative management of these agents.

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

“…The identified papers included reports about bariatric ( 1 , 27 , 31 – 37 ), cardiothoracic ( 2 , 38 – 46 ), neuro- ( 47 – 49 ), vascular ( 50 ), orthopedic ( 51 ), urologic ( 52 ), ophthalmologic ( 53 ), and visceral ( 2 , 49 , 54 , 55 ) surgery. Most of the interventions were elective, and therefore the time of withhold and restart were predominantly mentioned.…”

“…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 ).…”

“…Reported risk factors are prolonged fasting ( 27 ) and/or reduced oral intake ( 33 ) due to vomiting or dietary changes prior to weight loss surgery (very-low-calory diet) ( 34 ), huge weight loss after bariatric surgery ( 27 ), acute infection ( 38 ), basal insulin discontinuation and/or dose reduction before and/or after surgery ( 27 , 31 , 32 ), continuation of SGLT2-I medication perioperatively ( 46 , 55 ), or withholding within 24–48 h prior to elective interventions ( 47 , 54 ). Patients undergoing bariatric surgery might be at special risk for the development of EDKA because of surgical stress, perioperative diet changes, and prolonged fasting periods ( 31 , 34 , 36 , 37 , 52 , 59 , 61 ). The incidence of EDKA in diabetic cardiac bypass surgery patients indicates a worrisome potential of this side effect ( 2 , 38 – 46 ).…”

Perioperative Glycemic Management for Patients with and without Diabetes

“…Diabetes Canada (2018) 23 No recommendations No recommendations 5.0-10.0 mmol/L BBIT preferred American Diabetes Association (2019) 24 No recommendations Hold metformin on the day of surgery Alternatively, the Australian Diabetes and American Diabetes Associations suggest holding all noninsulin agents only on the morning of surgery. Recent concerns have arisen about the potential for diabetic ketoacidosis during the fasting period in patients taking sodium-glucose co-transporter 2 (SGLT-2) inhibitors 31,32 ; for this reason, the Canadian Anesthesiologists' Society has recommended holding SGLT-2 inhibitors 3 days prior to scheduled surgery. 33 Diabetes Canada does not make recommendations on how to manage noninsulin diabetes medications in the postoperative period, while other major society guidelines suggest restarting medications when the patient is eating or drinking well.…”

Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature

“…The time to onset of in those cases was around 24 hours, and the issue was identified and treated. The literature on euglycemic DKA in patients post-bariatric surgery is growing [ 11 , 16 - 19 ]. The onset of euglycemic DKA in these cases is often not as rapid as those described in the patients after cardiac surgery.…”