Abstract: SA-PO386
Euglycaemic Diabetic Ketoacidosis in Type 2 Diabetes: A Rare Complication of SGLT-2 Inhibitors
Session Information
- Genetic and Diagnostic Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 902 Fluid and Electrolytes: Clinical
Author
- Toal, Michael, Belfast City Hospital, Belfast, United Kingdom
Introduction
Diabetic ketoacidosis (DKA) is a commonly encountered condition worldwide, typically occurring in young patients with type 1 diabetes following a provoking illness. This case explores an atypical case of ketoacidosis in an elderly patient with type 2 diabetes, who was not on insulin treatment, providing a significant diagnostic challenge.
Case Description
An 81year old lady presented with a 48 hour history of poor oral intake, vomiting and dyspnea. Her past medical history was significant for schizophrenia and Type 2 Diabetes Mellitus. On examination she was dehydrated, but had an excellent urine output of over 100ml/hr.
Investigations revealed a raised anion gap metabolic acidosis (pH 7.08, Anion gap = 23) and ketonaemia of 5.47 mmol/l. Blood glucose, lactate and renal function were within normal range and the patient denied ingestion of toxins. Chest X-ray showed evidence of pneumonia. Treatment with two litres of intravenous fluids and antibiotics did not correct the acidosis, the pH falling from an initial rise of 7.22 to 7.09 and blood glucose of 10.7 to 9.9 mmol/l (178 mg/dl). Dapagliflozin was identified in the drug history as a potential precipitant of euglycaemic diabetic ketoacidosis. Intravenous infusions of dextrose and insulin successfully corrected the blood pH to 7.36 with a resolution of ketonaemia over the course of twenty four hours.
Discussion
Euglycaemic diabetic ketoacidosis (euDKA) is defined as the clinical triad of a blood glucose <11.1mmol/l (< 200mg/dl), raised anion gap metabolic acidosis and the presence of ketones in blood or urine.
Euglycaemic DKA has similar provoking factors to DKA, such as infection, fasting or surgery. This case is atypical as the patient was elderly and not on insulin treatment. The DECLARE (Dapagliflozin Effect on Cardiovascular Events) study with over 18,000 participants quoted an incidence of DKA in < 0.1% of patients on this treatment. The European Medicines Agency concluded in 2016 that life-threatening and fatal cases of diabetic ketoacidosis have been reported in patients treated with SGLT-2 inhibitors. SGLT-2 inhibitors act on the proximal convoluted tubule promoting urinary sodium and glucose excretion, inhibiting glucose reabsorption.
Clinicians should be mindful of this potentially life-threatening complication and consider euDKA in challenging cases of acid-base disturbance..