Euglycemic diabetes ketoacidosis associated with SGLT-2 inhibitors - review of case reports
DOI:
https://doi.org/10.12775/JEHS.2024.68.55325Keywords
sglt-2 inhibitors, euglycemic ketoacidosis, diabetes mellitus type 2, sodium-glucose cotransporter inhibitorsAbstract
AIM: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have gained significant importance in the treatment of type 2 diabetes mellitus. One of the adverse effects while using SGLT-2 inhibitors is euglycemic ketoacidosis (euDKA) - acute life-threatening emergency.
METHODS: The following review of case reports was based on articles published in 2023, obtained from the PubMed databases. Key search terms included “case report”, “sglt-2”, “sglt-2i”, “sodium-glucose cotransporter inhibitors”, “dka”. “eudka”, “euglycemic ketoacidosis”.
RESULTS: In the literature, cases of euDKA correlated with the use of SGLT-2 inhibitors are described.
CONCLUSION: There is a need for greater observation of the frequency of the adverse effects in patients taking sodium-glucose cotransporter inhibitors (SGLT-2i) and for raising awareness among doctors about the possibility of developing euglycemic diabetic ketoacidosis during the SGLT-2 inhibitors therapy.
References
Aksakal E, Duman H, Ulus T, Bayram E. Acute inferior pseudoinfarction pattern in a patient with normokalemia and diabetic ketoacidosis. Am J Emerg Med. 2009 Feb;27(2):251.e3-5. DOI: 10.1016/j.ajem.2008.06.024
Araszkiewicz, A., Bandurska-Stankiewicz, E., Borys, S. et. al.Guidelines on the management of patients with diabetes - a position of Diabetes Poland. Current Topics in Diabetes, 3(1), pp.1-133. DOI: 10.5114/ctd/160061
Baytuğan N.Z, Çelik A.I., Bezgin T., Çağdaş M. Euglycemic diabetic ketoacidosis associated with ST segment elevation myocardial infarction following SGLT-2 inhibitor therapy, The American Journal of Emergency Medicine, Volume 71, 2023, Pages 250.e1-250.e3, DOI: 10.1016/j.ajem.2023.07.007
Bonner C, Kerr-Conte J, Gmyr V, Queniat G et al. Inhibition of the glucose transporter SGLT2 with dapagliflozin in pancreatic alpha cells triggers glucagon secretion. Nat Med. 2015 May;21(5):512-7. doi: 10.1038/nm.3828
Blonde L., Umpierrez G.E, Reddy S.S., McGill J.B, Berga S.L., Bush M., Chandrasekaran S., DeFronzo R.A., Einhorn D. et al. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan—2022 Update, Endocrine Practice, Volume 28, Issue 10, 2022, Pages 923-1049, DOI: 10.1016/j.eprac.2022.08.002
Campbell I.W., Duncan L.J., Clarke B.F. Pericarditis in diabetic ketoacidosis. Br. Heart J. 1977; 39: 110–112. doi: 10.1136/hrt.39.1.110
Chauhan S, Manov A, Dhillon GS, Shah P. Empagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient With Type 2 Diabetes Mellitus. Cureus. 2023 Jan 17;15(1):e33892. doi: 10.7759/cureus.33892
Cohen A., Utarnachitt RV. Electrocardiographic changes in a patients with hyperkalemia and diabetic acidosis associated with acute anteroseptal pseudomyocardial infarction and bifascicular block. Angiology. 1981 May;32(5):361-4. doi: 10.1177/000331978103200510.
Douros A, Lix LM, Fralick M, et al., Canadian Network for Observational Drug Effect Studies (CNODES) Investigators. Sodium-Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis : A Multicenter Cohort Study. Ann Intern Med. 2020 Sep 15;173(6):417-425. doi: 10.7326/M20-0289
European public assessment report (EPAR): Forxiga, dapagliflozin, Date of authorisation: 11/11/2012, Revision: 30, https://www.ema.europa.eu/en/medicines/human/EPAR/forxiga Annex 1 Summary of product characteristics
European public assessment report (EPAR): Jardiance, empagliflozin, Date of authorisation: 22/05/2014, Revision: 29, Https://www.ema.europa.eu/en/medicines/human/EPAR/jardiance Annex 1 Summary of product characteristics
European Medicines Agency. Human Medicines. SGLT2 inhibitors: PRAC makes recommendations to minimise risk of diabetic ketoacidosis; https://www.ema.europa.eu/en/news/ema-confirms-recommendations-minimise-ketoacidosis-risk-sglt2-inhibitors-diabetes
Food and Drug Administration safety announcement issued on May 15, 2015 https://www.fda.gov/drugs/drug-safety-and-availability/fda-revises-labels-sglt2-inhibitors-diabetes-include-warnings-about-too-much-acid-blood-and-serious
Friedberg, C. K. Diseases of the Heart, 3rd ed., p. 1663. W. B. Saunders, Philadelphia. 1966 ISBN-10: 0721639062
Gajewski P. et. al. Szczeklik’s Internal Medicine: Small Manual, 14th ed., Medycyna praktyczna, Kraków, 2022 ISBN: 978-7430-670-6
Haddadin R, Aboujamra D, Iraninezhad H. Sodium-Glucose Cotransporter-2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a Type 2 Diabetic Patient. Cureus. 2023 Dec 27;15(12):e51184. doi: 10.7759/cureus.51184. PMID: 38283482; PMCID: PMC10817760.
S. Halimi, B. Vergès, Adverse effects and safety of SGLT-2 inhibitors, Diabetes & Metabolism, Volume 40, Issue 6, Supplement 1, 2014, Pages S28-S34, ISSN 1262-3636, doi: 10.1016/S1262-3636(14)72693-X
Heidenreich Paul A., Bozkurt Biykem, Aguilar David et. al. AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, Journal of the American College of Cardiology, Volume 79, Issue 17, 2022, Pages 1757-1780, ISSN 0735-1097, DOI: 10.1016/j.jacc.2021.12.011
Kawahara, J., Kaku, B., Yagi, K. et al. Life-threatening coronary vasospasm in patients with type 2 diabetes with SGLT2 inhibitor-induced euglycemic ketoacidosis: a report of two consecutive cases. Diabetol Int 15, 135–140 (2024). DOI: 10.1007/s13340-023-00664-8
Klinkner G., Steingraber-Pharr M.; Euglycemic Diabetic Ketoacidosis Associated With SGLT2 Inhibitor Therapy: A Case Report. AACN Adv Crit Care 15 March 2023; 34 (1): 27–32. doi: 10.4037/aacnacc2023830
Levine HD, Wanzer SH, Merrill JP. Dialyzable currents of injury in potassium intoxication resembling acute myocardial infarction or pericarditis. Circulation. 1956 Jan;13(1):29-36. doi: 10.1161/01.cir.13.1.29. PMID: 13277089.
Lim YH, Anantharaman V. Pseudo myocardial infarct--electrocardiographic pattern in a patient with diabetic ketoacidosis. Singapore Med J. 1998 Nov;39(11):504-6. PMID: 10067388.
Madaan M, Aggarwal K, Sharma R, Trivedi SS. Diabetic ketoacidosis occurring with lower blood glucose levels in pregnancy: a report of two cases. J Reprod Med. 2012 Sep-Oct;57(9-10):452-5. PMID: 23091997.
Maruyama H, Hisatomi A, Orci L, Grodsky GM, Unger RH. Insulin within islets is a physiologic glucagon release inhibitor. J Clin Invest. 1984 Dec;74(6):2296-9. doi: 10.1172/JCI111658. PMID: 6392344; PMCID: PMC425424.
Moulik PK, Nethaji C, Khaleeli AA. Misleading electrocardiographic results in patient with hyperkalaemia and diabetic ketoacidosis. BMJ. 2002 Dec 7;325(7376):1346-7. doi: 10.1136/bmj.325.7376.1346. PMID: 12468487; PMCID: PMC1124804.
Ogawa W, Sakaguchi K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. J Diabetes Investig. 2016 Mar;7(2):135-8. doi: 10.1111/jdi.12401. Epub 2015 Sep 6. PMID: 27042263; PMCID: PMC4773669.
Petersen C, Gyabaah F, Sotelo J, Yohanna S, Deoker A. A Case of Prolonged Recovery for Post-percutaneous Coronary Intervention (PCI) Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a 28-Year-Old. Cureus. 2023 Sep 13;15(9):e45180. doi: 10.7759/cureus.45180. PMID: 37842482; PMCID: PMC10575758.
Rathore A, Gupta N, Kahn C, Kadariya D. Euglycemic diabetic ketoacidosis caused by empagliflozin complicated by failure to thrive in a geriatric patient. Arch Clin Cases. 2023 Jun 12;10(2):89-92. doi: 10.22551/2023.39.1002.10248. PMID: 37313125; PMCID: PMC10258732.
Rosenstock J, Ferrannini E. Euglycemic Diabetic Ketoacidosis: A Predictable, Detectable, and Preventable Safety Concern With SGLT2 Inhibitors. Diabetes Care. 2015 Sep;38(9):1638-42. doi: 10.2337/dc15-1380. PMID: 26294774.
Rossing P., M. Caramori L.,Chan J.C.N. et. al. Executive summary of the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease: an update based on rapidly emerging new evidence, Kidney International, Volume 102, Issue 5, 2022, Pages 990-999, ISSN 0085-2538, DOI: 10.1016/j.kint.2022.06.013
Sarno MJF, Hernandez DPF, Matulac MO. "Normal but Catastrophic" Euglycemic Diabetic Ketoacidosis Precipitated by Sodium-Glucose Cotransporter-2 Inhibitor Use: A Case Report. Cureus. 2023 Nov 22;15(11):e49236. doi: 10.7759/cureus.49236. PMID: 38143642; PMCID: PMC10740381.
Sharma E, Dahal S, Sharma P, Ghimire DK, Dahal S. A Case of Pseudoinfarction Pattern in Diabetic Ketoacidosis: A Diagnostic and Therapeutic Dilemma. Cardiol Res. 2018 Aug;9(4):250-252. doi: 10.14740/cr747w. Epub 2018 Aug 10. PMID: 30116454; PMCID: PMC6089466.
Sims DB, Sperling LS. Images in cardiovascular medicine. ST-segment elevation resulting from hyperkalemia. Circulation. 2005 May 17;111(19):e295-6. doi: 10.1161/01.CIR.0000165127.41028.D1. PMID: 15897351.
Tiwari K, Sharma NR, Pokhrel M, Basnet A, Kaplan M. Misleading Presentation: Chest Pain Masking Euglycemic Diabetic Ketoacidosis Possibly Induced by Empagliflozin. Cureus. 2023 Nov 25;15(11):e49402. doi: 10.7759/cureus.49402. PMID: 38149142; PMCID: PMC10749796.
Ziakas A, Basagiannis C, Stiliadis I. Pseudoinfarction pattern in a patient with hyperkalemia, diabetic ketoacidosis and normal coronary vessels: a case report. J Med Case Rep. 2010 Apr 26;4:115. doi: 10.1186/1752-1947-4-115. PMID: 20420664; PMCID: PMC2876172.
Zughaib, M, Basharat, B, Small, D. A Case of STEMI-Induced Euglycemic Diabetic Ketoacidosis in a Patient Receiving a Sodium Glucose Cotransporter-2 Inhibitor. J Am Coll Cardiol Case Rep. 2023 Apr, 11 (null). .DOI: 10.1016/j.jaccas.2023.101792
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Joanna Winciorek, Piotr Cyran, Anna Jaroszyńska, Filip Jaroszyński, Joanna Kowal, Jan Paleczny, Robert Parobczak, Paweł Jakub Połujański, Adrianna Marta Wiśniewska
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The periodical offers access to content in the Open Access system under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
Stats
Number of views and downloads: 69
Number of citations: 0
