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
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