Abstract
Euglycemic diabetic ketoacidosis (EuDKA) secondary to Sodium-glucose co-transporter-2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2D) is a rare but increasingly reported phenomenon. Not much is known about the burden of EuDKA in patients on SGLT2i or the associated factors. This retrospective cohort study tries to delineate the differences in factors associated with the development of EuDKA as compared to hyperglycemic DKA. We conducted a multicentre, retrospective study across three tertiary care centers under Weill Cornell affiliated-Hamad Medical Corporation, Qatar. The cohort comprised of T2D patients on SGLT2i who developed DKA between January 2015 to December 2020. The differences between the subjects who developed EuDKA or hyperglycaemic DKA (hDKA) were analyzed. A total of 9940 T2D patients were on SGLT2i during 2015–2020, out of which 43 developed DKA (0.43%). 25 developed EuKDA, whereas 18 had hDKA. The point prevalence of EuDKA in our cohort was 58.1%. EuDKA was most common in patients using canagliflozin, followed by empagliflozin and Dapagliflozin (100%, 77%, and 48.3%, respectively). Overall, infection (32.6%) was the most common trigger for DKA, followed by insulin non-compliance (13.7%). Infection was the only risk factor with a significant point estimate between the two groups, being more common in hDKA patients (p-value 0.006, RR 2.53, 95% CI 1.07–5.98). Canagliflozin had the strongest association with the development of EuDKA and was associated with the highest medical intensive care unit (MICU) admission rates (66.6%). In T2D patients on SGLT2i, infection is probably associated with an increased risk of developing EuDKA. The differential role of individual SGLT2i analogs is less clear and will need exploration by more extensive prospective studies.
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Introduction
SGLT2i is a relatively newer class of oral drugs for the management of T2D1. Their predominant mechanism of action lies in preventing glucose reabsorption from the proximal renal tubules by targeting the sodium-glucose transporter 22. The most common adverse effect of SGLT2i is urinary tract infections3. A less common yet equally important side-effect associated with SGLT2i is DKA. SGLT-2 associated DKA is not an extensively studied phenomenon4.
DKA is more common in type 1 diabetes mellitus (T1D) than T2D (50–100 and 4.6–8 episodes per 1000 patients, respectively)5,6. However, it remains a significant cause of morbidity in the T2D population because of an overall higher prevalence of T2D itself (8.5% compared to 0.5% prevalence of T1D)7. DKA remains a significant healthcare burden with an estimated annual cost exceeding 1 billion USD8. DKA has been observed in T2D patients taking Glucagon-Like Peptide 1 Receptor (GLP-1) agonists and Dipeptidyl peptidase-4 (DPP-4) inhibitors9,10. However, the risk of DKA with SGLT2i is two to three times more than other oral T2D medications4,10.
EuDKA is a relatively new phenomenon that has most commonly been defined as ketoacidosis (pH ≤ 7.3, bicarbonate ≤ 15 mmol/L, anion gap > 12 mmol/L) in the presence of euglycemia (blood sugar < 14 mmol/L)7. The pathophysiology of DKA is the relative or absolute insulin-deficient state of the body11. Random blood sugar (RBS) testing is one of the easiest, rapid, readily available, and usually, the first test gives a real-time status of the blood sugar. This measurement is utilized to make a rapid diagnosis of DKA in home and hospital settings, irrespective of the healthcare system's resource status. However, RBS cannot be used as a “direct biomarker” for the body's insulin-deficient state in EuDKA. The RBS may misinform regarding the state of insulin deficiency in subjects using SGLT2i due to glucosuria leading to lower than anticipated serum glucose level despite a relative insulin-deficient state.
In 2015 FDA issued a warning regarding the risk of DKA with SGLT2i12. Clark et al. have recently provided the largest evidence of SGLT2i led DKA in the adult population13. Considering the emerging evidence, FDA in August 2020 released a recommendation to hold SGLT2i in diabetic patients before surgical procedures to avoid the development of DKA14. Due to the low prevalence of DKA (EuDKA and hDKA) in T2D patients taking SGLT2i, a comparative assessment of the two subsets is an area of interest. Often DKA of whatever phenotype (EuDKA or hDKA) are usually fraught with demonstrable morbidity and sometimes excess mortality. However, there has not been a comprehensive examination of the true burden and exact clinical phenotype of EuDKA in T2D patient cohorts on SGLT2i analogs. In this study, we conducted a retrospective examination on T2D patients on SGLT2i who developed DKA to ascertain the prevalence, demography, risk factors, and outcomes associated with the development of EuDKA.
Methods
Study design
We performed a cross-sectional, multicentre, retrospective study on T2D patients taking SGLT2i who developed either EuDKA or hDKA from January 2015 to December 2020.
Inclusion criteria
All patients with T2D using SGLT2i and admitted to the three hospitals of Weill Cornell Medicine affiliated-Hamad Medical Corporation, Qatar, with diabetic ketoacidosis between 2015 and 2020 were included in the study. The patient cohort comprised patients who had a prior diagnosis of T2D based on HBA1C ≥ 47.5 mmol/mol (6.5%); fasting glucose ≥ 7.0; use of oral hypoglycaemic drugs with or without insulin use; patients were on one of the SGLT2i at the time of admission with DKA. The ketoacidosis diagnosis was made based on the following set of parameters: pH < 7.3, anion gap > 12 mmol/L, and ketonemia/ketonuria. Patients were further subdivided into EuDKA or hDKA based on the presence of either euglycemia (RBS < 14 mmol/L) or hyperglycemia (RBS ≥ 14 mmol/L). Patients who had DKA with T1D and those who had DKA with T2D but were not on SGLT2i were excluded from the study. Similarly, patients with T2D on SGLT2i admitted with a diagnosis of DKA who did not meet the definition of DKA (due to anion gap < 12) were excluded from the analysis (n = 3).
Data was abstracted from electronic records of Hamad Medical Corporation patient data repository (Cerner). Data collected includes demographics such as age, sex, ethnicity, body mass index (BMI), comorbid conditions, temperature, and relevant laboratory investigations at admission. Data related to patients’ diabetes status included HBA1c recorded on or 2–4 weeks before presentation, point of care (POC) glucose at admission, oral hypoglycaemic drugs, insulin use, concordance, and diabetic complications. The use and type of SGLT2i were confirmed from the medication histories and admission and discharge summaries of the included patients. Data collected for DKA includes relevant laboratory investigations such as PH, anion gap, lactic acid, POC glucose level, blood/urine ketones, possible triggering factors, DKA duration, hospital days, need for MICU admission, and in-hospital mortality.
Statistical analyses
Descriptive and summary statistics were used to describe the study cohort’s socio-demographic parameters, with continuous variables presented as means (± SD) or median (interquartile range) as appropriate. In contrast, categorical variables were presented as numbers (percentages). The Shapiro–Wilk tests analyzed the normality of the data. Pairwise comparisons between continuous and categorical study variables were carried out with student t-test and chi-square tests, respectively. Kruskal–Wallis test and one way ANNOVA tests were used to compare the variables among the subgroups. We used a multiple linear regression model to analyze the associations of some of the more relevant independent variables with glucose at admission. These variables included fasting glucose within three months before admission (significant difference found in One-Way ANOVA), infections (significant difference found in Kruskal–Wallis test), diabetic retinopathy and compliance to insulin (reflecting the progression of diabetes and patient compliance to treatment), type of SGLT2i (to analyze any relation of different SGLT2i on glucose at admission). All data were analyzed using Jamovi version 1.2 (created in 2020, Sydney, Australia)15.
All methods were performed in accordance with the relevant guidelines and regulations and were in accordance with the Declaration of Helsinki. As this is a retrospective review of medical records, informed consent was waived by the Medical Research Center (MRC) Qatar.
Ethics declaration
This work is original, has not been, and is not under consideration for publication in any other Journal. All authors have reviewed and approved the final version of the manuscript. The study was approved by the Medical Research Centre (MRC) Qatar (MRC-01-20-064).
Consent to participate
Informed consent was not required, as this study was a retrospective data review of medical records.
Consent for publication
Informed consent was not required, as this study was a retrospective data review of medical records.
Results
Baseline characteristics
Table 1 gives a summary of the patients’ baseline characteristics. During the five years (2015–2020), a total of 9940 T2D patients were on SGLT2i in the inpatient and outpatient settings of the three hospitals of Hamad Medical Corporation. Among these,43 developed DKA (prevalence: 0.43%). Out of 43 patients, 25 had EuDKA (prevalence: 0.25%) (10 males,15 females), and 18 had hDKA (prevalence: 0.18%) (9 males,9 females). The Mean age in EuDKA and hDKA was 52.4 (± 12.8) and 58.9 (± 12.9), respectively. There was a high proportion of patients from the Middle East-North Africa (MENA) region (n = 32; 20 EuDKA,12 hDKA). Mean BMI in EuDKA and hDKA were 30.2 (± 7.19) and 29.4 (± 6.17), respectively.
Laboratory results and clinical outcomes in EuDKA and hDKA groups
Median RBS at admission was 10.3 (9.3–11.9) in EuDKA and 21.8 (17.3–26.9) in hDKA. The difference was statistically significant, as expected (p value < 0.001). Mean fasting glucose (measured within three months before admission) was 9.32 ± 2.86 in EuDKA and 12.6 ± 3.88 in the hDKA group (p value 0.023). Diabetic complications were more frequent in the EuDKA group compared to hDKA. The difference in the frequency of diabetic retinopathy ( 16% in EuDKA and 11.1% in hDKA) was statistically significant (p-value 0.02). Mean HbA1c was 80.8 mmol/mol (9.54% ± 1.82) in EuDKA and 86.9 mmol/mol (10.1% ± 2.12) in hDKA [Table 1]. EuDKA patients had a median pH of 7.28 (7.16–7.32), while hDKA had 7.21 (7.07–7.32). The median length of stay was five days in both groups (IQR 4–12 in EuDKA and 3–7.75 in hDKA). The median collective anion gap was 20 (17.5–22.6), with comparable results in both groups [Table 1]. Median DKA duration was 2 (IQR 2–3) days in EuDKA and 2.5 (IQR 2–4) days in hDKA. The intensive care unit admissions rate was similar in both groups [Table 1].
Precipitating factors
Infection was the most common trigger overall (32.6%), followed by insulin non-compliance (13.7%), pancreatitis (4.7%), and surgery (2.3%); precipitating factors had a similar trend in both EuDKA and hDKA except for infections, which was more in hDKA patients compared to EuDKA (RR 2.53, 95% CI 1.07–5.98 p value 0.006). The difference remained significant after multiple linear regression analysis (p-value 0.039).
Results based on SGLT2-i type
Among the total population on SGLT2i (9940 patients), the prevalence of total DKA, EuDKA, and hDKA in patients taking Dapagliflozin (7280 patients) was 0.43%, 0.21%, and 0.23%, respectively. The prevalence of total DKA, EuDKA, and hDKA in patients taking Empagliflozin (2646) was 0.34%, 0.26%, and 0.08%. Lastly, the prevalence of total DKA and EuDKA in patients taking Canagliflozin (14 patients) was 0.21%. The prevalence of hDKA in patients on Canagliflozin could not be calculated due to the small sample size. In our cohort of 43 T2D patients who developed DKA, the most common SGLT2i used was Dapagliflozin (72%), followed by empagliflozin (20.9%) and canagliflozin (7%). EuDKA was most commonly found in patients using canagliflozin (100%, n = 3), followed by empagliflozin (77.7%) and Dapagliflozin (48.3%). However, no statistically significant difference was found in the development of EuDKA with any particular type of SGLT2i after multiple linear regression. MICU admission rate was 66.6% in patients on canagliflozin, 45.1% in Dapagliflozin, and 33.3% in the empagliflozin group. In-hospital mortality was only noted in the dapagliflozin group (3.2% OR 0.293 CI 0.01–7.7). The median length of stay in canagliflozin, Dapagliflozin, and empagliflozin was 4 (IQR 3–4.5), 5 (3–9), and 9 (IQR 2–16) days, respectively. Median DKA duration was 2 (IQR 2–2.5) in canagliflozin, 3 (2–4) in Dapagliflozin, and 2 (2–3) days in the empagliflozin group. Median pH was 7.17 (IQR 7.17–7.22) in canagliflozin, 7.21 (IQR 7.21–7.31) in dapagliflozin, and 7.29 (IQR 7.29–7.34) in the empagliflozin group [Table 2].
Discussion
This study represents the first comprehensive evaluation of the prevalence and determinants of EuDKA in a cohort of T2D patients exposed to SGLT2i. In a population of 9940 T2D patients taking SGLT2i during five years (2015–2020), 43 developed DKA. In this cohort, we found the point prevalence of EuDKA at 58.1% amongst T2D patients within our cohort. Previously a point prevalence of 69.8% for EuDKA in T2D and T1D combined is reported by Clark et al.13. Our cohort excluded T1D patients because the FDA does not recommend SGLT2i use in this population16. Additionally, we found infections and insulin non-adherence as the key drivers to development and presentation with EuDKA.
In our study, precipitators of EuDKA were similar to previous studies, with a notable exception of fasting, which was not found in any of our patients who developed EuDKA [Table 1]. We did not find any previously known precipitator in 22 patients. As discussed by Clark et al., we also think that SGLT2i use could have led to DKA in these patients in the absence of additional triggers13. However, there is a possibility of other precipitating factors that could not be assessed in our study. The median length of stay (LOS) in our study varied from 4 to 9 days, depending upon the type of SGLT2i. Variable LOS is reported before, ranging from 3.53 to 6 days13,17. The median time to close the anion gap was 2–3 days, based on the type of SGLT2i used, which is almost double compared to the previous13,17.
In a review of 101 case reports, the highest number (63 cases) of DKA was seen in patients taking canagliflozin, reflected in our study. Hence, Canagliflozin is probably most strongly associated with the development of EuDKA18. We also reviewed and tabulated data from the latest 30 case reports describing EuDKA secondary to SGLT2i in T2D patients19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48 [Table 3]. Our study showed a slightly higher prevalence of EuDKA in females, which was not statistically significant [Table 1]. Previous retrospective study and our review of the last 30 case reports showed a slight male predominance13 [Table 3]. Reviews that have been solely on case reports have shown a considerable difference with 75% prevalence in females49. Fasting has been reported as the most common precipitator in the case reports (47.5%), whereas it was 14% in the previous descriptive study on 43 patients (including 25 with T2D) and 0% in our study. Analysis of case reports is relevant in rare diseases in the absence of more extensive studies. However, any conclusions drawn from case reports must be reconsidered when data from more extensive studies with a more representative cohort becomes available.
EuDKA and hDKA have different pathophysiologies. In EuDKA, there is a relatively milder intensity of insulin deficiency and resistance. Moreover, urinary glucose clearance in EuDKA is double compared to hDKA (estimated around 0.3 ml/min/kg in hDKA and 0.6 ml/min/kg in EuDKA)50. Considering distinct pathophysiologies, differences in precipitators, presentations, clinical course, and outcomes can be expected. To evaluate this, we compared patient demographics, presentation, clinical course, and outcomes in patients with EuDKA and hDKA. To the best of our knowledge, there are no prior studies comparing EuDKA and hDKA in the T2D population taking SGLT2i. Our study found some key clinical differences. Firstly, EuDKA was probably more prevalent in females (60%), whereas hDKA did not seem to have a gender preference. Secondly, the median RBS in EuDKA and hDKA differed as expected (10.3 vs. 21.8 mmol/l). Among the precipitators, surgery seemed to be more associated with the development of EuDKA as compared to hDKA, and insulin non-compliance was probably more common in hDKA compared to EuDKA. Among the SGLT2i types, Dapagliflozin was probably the most commonly associated with both types of DKA, followed by Empagliflozin and Canagliflozin (which seemed to be mainly associated with EuDKA as none of our T2D patients on Canagliflozin developed hDKA). ICU admission rates were comparable in both groups. However, mortality seemed to be more associated with EuDKA, although our sample size was not powered to analyze mortality. Although many clinical differences among the two groups exist, we only found statistically significant differences in rates of infections, diabetic retinopathy, fasting, and random blood glucose levels. A more extensive comparison between EuDKA and hDKA in T2D patients taking SGLT2i with larger sample sizes can validate our results.
The phenomenon of EuDKA has been reported in the literature as early as 198951. However, with the advent and success of SGLT2i in T2D management, it has become a focus of discussion in diabetology. Although it is a rare phenomenon, the scale of use of SGLT2i has led to an increasing number of cases of EuDKA. Throughout the years, its definition has evolved. The current definition of EuDKA is the presence of ketoacidosis with a pH ≤ 7.3, bicarbonate ≤ 15 mmol/l, anion gap > 12 mmol/l in the setting of lower-than-expected glucose level (RBS < 14 mmol/l)13. SGLT2i use is increasing due to its positive effects on glycaemic control, body weight, heart failure exacerbations, and cardiovascular deaths52,53.
The mechanism of EuDKA secondary to SGLT2i is not yet fully understood. Perry RJ et al. conducted a study on healthy and T2D rats given SGLT2i. They concluded that low insulin levels and dehydration promote EuDKA by raising serum catecholamine and corticosterone levels, leading to increased white adipose tissue lipolysis54. A similar mechanism has been proposed in humans with propositions that euglycemia occurs in the setting of SGLT2i associated DKA when the renal glucose clearance exceeds endogenous glucose production55,56.
Our study’s principal strength lies in its novelty in carrying out the first comprehensive exploration of the distribution, determinants, and other factors impacting the outcomes of T2D patients with EuDKA.
Our study has some limitations inherent when reviewing such data schemes. Firstly, its retrospective design meant difficulties were encountered with missing values and case adjudication, especially those of precipitating factors. Secondly, owing to its low incidence, our sample size was small; a bigger sample size could improve our results’ validity and generalizability. A more extensive prospective study on T2D patients on SGLT2i may yield more reliable results regarding risk factors and pathophysiology of EuDKA in this population.
Conclusion
In our cohort of T2D patients taking SGLT2i, the prevalence of DKA is around 0.43%, with a prevalence of EuDKA and hDKA 0.25% and 0.18%, respectively. Overall, DKA (including EuDKA) was primarily triggered by infection. Additionally, patients with more complicated diabetes are probably prone to develop EuDKA compared to hDKA. The differential contribution of specific SGLT2i analogs remains uncertain and will need examination by larger sample-sized prospective studies.
Data availability
Available upon request.
Code availability
Available upon request.
Abbreviations
- EuDKA:
-
Euglycemic diabetic ketoacidosis
- hDKA:
-
Hyperglycaemic DKA
- T2D:
-
Type 2 diabetes mellitus
- T1D:
-
Type 1 diabetes mellitus
- SGLT2i:
-
Sodium-glucose co-transporter-2 inhibitors
- MICU:
-
Medical intensive care unit
- GLP-1:
-
Glucagon-like peptide 1 receptor
- DPP-4:
-
Dipeptidyl peptidase-4
- RBS:
-
Random blood sugar
- BMI:
-
Body mass index
- POC:
-
Point of care
- LOS:
-
Length of stay
References
9. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2020. Diabetes Care 43, S98–S110.https://doi.org/10.2337/dc20-S009 (2020).
Ogawa, W. & Sakaguchi, K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. J. Diabetes Investig. 7, 135–138. https://doi.org/10.1111/jdi.12401 (2016).
Yang, Y., Chen, S., Pan, H., Zou, Y., Wang, B. et al. Safety and efficiency of SGLT2 inhibitor combining with insulin in subjects with diabetes: Systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 96, e6944. https://doi.org/10.1097/md.0000000000006944 (2017).
Douros, A. et al. Sodium-glucose cotransporter-2 inhibitors and the risk for diabetic ketoacidosis : a multicenter cohort study. Ann. Intern. Med. 173, 417–425. https://doi.org/10.7326/m20-0289 (2020).
Puttanna, A. & Padinjakara, R. Diabetic ketoacidosis in type 2 diabetes mellitus. Pract. Diabetes 31, 155–158. https://doi.org/10.1002/pdi.1852 (2014).
Fazeli Farsani, S. et al. Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open 7, e016587. https://doi.org/10.1136/bmjopen-2017-016587 (2017).
Xu, G. et al. Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: population based study. BMJ 362, k1497. https://doi.org/10.1136/bmj.k1497 (2018).
Kitabchi, A. E. et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24, 131–153. https://doi.org/10.2337/diacare.24.1.131 (2001).
Diabetic ketoacidosis with GLP-1 receptor agonists, insulin. React. Week. 1760, 1–1, doi:https://doi.org/10.1007/s40278-019-64160-9 (2019).
Fralick, M., Schneeweiss, S. & Patorno, E. Risk of Diabetic Ketoacidosis after Initiation of an SGLT2 Inhibitor. New Engl. J. Med. 376, 2300–2302. https://doi.org/10.1056/NEJMc1701990 (2017).
Steel, S. & Tibby, S. M. Paediatric diabetic ketoacidosis. Continu. Educ. Anaesth. Crit. Care Pain 9, 194–199. https://doi.org/10.1093/bjaceaccp/mkp034 (2009).
Administration, U. S. F. A. D. FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood, https://www.fda.gov/media/92185/download (2015).
Clark, A. et al. Prevalence and clinical characteristics of adults presenting with sodium-glucose cotransporter-2 inhibitor-associated diabetic ketoacidosis at a Canadian Academic Tertiary Care Hospital. Can. J. Diabetes https://doi.org/10.1016/j.jcjd.2020.08.100 (2020).
Addendum. 9. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2020. Diabetes Care 2020;43(Suppl. 1):S98-S110. Diabetes Care 43, 1979, https://doi.org/10.2337/dc20-ad08a (2020).
The jamovi project (2020). jamovi (Version 1.2) [Computer Software], https://www.jamovi.org (2020).
Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/sodium-glucose-cotransporter-2-sglt2-inhibitors (2018).
Clark, A. et al. Evaluation of a diabetic ketoacidosis order set in adults with type 1 and type 2 diabetes at a tertiary academic medical centre: a retrospective chart audit. Can. J. Diabetes 43, 304-308.e303. https://doi.org/10.1016/j.jcjd.2018.11.004 (2019).
Singh, A. K. Sodium-glucose co-transporter-2 inhibitors and euglycemic ketoacidosis: Wisdom of hindsight. Indian J. Endocrinol. Metab. 19, 722–730. https://doi.org/10.4103/2230-8210.167554 (2015).
Albugami, M. M., Ahmed, M. & Alobaid, D. Empagliflozin-induced euglycemic diabetic ketoacidosis in type 2 diabetes mellitus. Saudi J. Med. Med. Sci. 8, 241–242. https://doi.org/10.4103/sjmms.sjmms_325_20 (2020).
Batista, D. V., Vieira, C., Costa, T. A. & Lima, E. G. COVID-19-associated euglycemic diabetic ketoacidosis in a patient with type 2 diabetes on SGLT2 inhibitor: a case report. Diabetol Int. https://doi.org/10.1007/s13340-020-00473-3 (2020).
Dorcely, B. et al. A Case report: euglycemic diabetic ketoacidosis presenting as chest pain in a patient on a low carbohydrate diet. Curr. Diabetes Rev. https://doi.org/10.2174/1573399816666200316112709 (2020).
Earle, M., Ault, B. & Bonney, C. Euglycemic diabetic ketoacidosis in concurrent very low-carbohydrate diet and sodium-glucose transporter-2 inhibitor use: a case report. Clin. Pract. Cases Emerg. Med. 4, 185–188. https://doi.org/10.5811/cpcem.2020.2.45904 (2020).
Fukuda, M., Nabeta, M., Muta, T., Fukami, K. & Takasu, O. Euglycemic diabetic ketoacidosis caused by canagliflozin: a case report. Int. J. Emerg. Med. 13, 2. https://doi.org/10.1186/s12245-020-0261-8 (2020).
Fukuyama, Y., Numata, K., Yoshino, K., Santanda, T. & Funakoshi, H. Euglycemic diabetic ketoacidosis due to a strict low-carbohydrate diet during treatment with sodium-glucose cotransporter 2 inhibitors. Acute Med. Surg. 7, e480. https://doi.org/10.1002/ams2.480 (2020).
Gajjar, K. & Luthra, P. Euglycemic diabetic ketoacidosis in the setting of SGLT2 inhibitor use and hypertriglyceridemia: a case report and review of literature. Cureus 11, e4384. https://doi.org/10.7759/cureus.4384 (2019).
Garay, P. S., Zuniga, G. & Lichtenberg, R. A Case of euglycemic diabetic ketoacidosis triggered by a ketogenic diet in a patient with type 2 diabetes using a sodium-glucose cotransporter 2 inhibitor. Clin. Diabetes 38, 204–207. https://doi.org/10.2337/cd19-0055 (2020).
Iqbal, I., Hamid, M., Khan, M. A. A., Kainat, A. & Tariq, S. Dapagliflozin-induced late-onset euglycemic diabetic ketoacidosis. Cureus 11, e6089. https://doi.org/10.7759/cureus.6089 (2019).
Kitahara, C. et al. Early detection of euglycemic ketoacidosis during thoracic surgery associated with empagliflozin in a patient with type 2 diabetes: A case report. J. Diabetes Investig https://doi.org/10.1111/jdi.13365 (2020).
Latif, A., Gastelum, A. A., Sood, A. & Reddy, J. T. Euglycaemic diabetic ketoacidosis in a 43-year-old woman with type 2 diabetes mellitus on SGLT-2 inhibitor (empagliflozin). BMJ Case Rep. https://doi.org/10.1136/bcr-2020-235117 (2020).
Lee, I. H. & Ahn, D. J. Dapagliflozin-associated euglycemic diabetic ketoacidosis in a patient with type 2 diabetes mellitus: A case report. Medicine (Baltimore) 99, e20228. https://doi.org/10.1097/md.0000000000020228 (2020).
Mackintosh, C., Tewari, A., Siegel, J., Wang, R. D. & Freeman, W. Postoperative euglycemic diabetic ketoacidosis and encephalopathy related to SGLT-2 inhibitors: a case report and discussion of diabetes treatment and “sweet pee encephalopathy” in perioperative hospital management. Neurohospitalist 10, 51–54. https://doi.org/10.1177/1941874419835035 (2020).
Mendelsohn, R. A., Taveras, A. N., Mazer, B. A. & Clayton, L. M. Euglycemic diabetic ketoacidosis precipitated by SGLT-2 inhibitor use, pericarditis, and fasting: a case report. Clin. Pract. Cases Emerg. Med. 4, 389–392. https://doi.org/10.5811/cpcem.2020.4.46056 (2020).
Menghoum, N., Oriot, P., Hermans, M. P. & Mariage, J. L. Diabetic euglycemic ketosis or ketoacidosis in individuals with type 2 diabetes treated by SGLT2 inhibitors: A series of Belgian clinical cases. Rev. Med. Intern. 41, 226–231. https://doi.org/10.1016/j.revmed.2019.12.006 (2020).
Meyer, E. J. et al. Periprocedural euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter 2 inhibitor therapy during colonoscopy. Diabetes Care 43, e181–e184. https://doi.org/10.2337/dc20-1244 (2020).
Miwa, M., Nakajima, M., Kaszynski, R. H. & Goto, H. Prolonged euglycemic diabetic ketoacidosis triggered by a single dose of sodium-glucose cotransporter 2 inhibitor. BMJ Case Rep. https://doi.org/10.1136/bcr-2020-235969 (2020).
Nappi, F. et al. Nephrology consultation for severe SGLT2 inhibitor-induced ketoacidosis in type 2 diabetes: case report. Medicina (Kaunas) https://doi.org/10.3390/medicina55080462 (2019).
Oriot, P. & Hermans, M. P. Euglycemic diabetic ketoacidosis in a patient with type 1 diabetes and SARS-CoV-2 pneumonia: case report and review of the literature. Acta Clin. Belg. https://doi.org/10.1080/17843286.2020.1780390 (2020).
Ozer, O. & Yorulmaz, G. Euglycemic diabetic ketoacidosis associated with empagliflozin use in the course of the SARS-Cov-2 pandemic. J. Coll. Phys. Surg. Pak. 30, 110–111. https://doi.org/10.29271/jcpsp.2020.10.110 (2020).
Papadokostaki, E. & Liberopoulos, E. Euglycemic diabetic ketoacidosis secondary to dapagliflozin in a patient with colon malignancy. Case Rep. Endocrinol. 2019, 3901741. https://doi.org/10.1155/2019/3901741 (2019).
Rafey, M. F. et al. Prolonged acidosis is a feature of SGLT2i-induced euglycaemic diabetic ketoacidosis. Endocrinol. Diabetes Metab. Case Rep. https://doi.org/10.1530/edm-19-0087 (2019).
Sampani, E. et al. Severe euglycemic diabetic ketoacidosis of multifactorial etiology in a type 2 diabetic patient treated with empagliflozin: case report and literature review. BMC Nephrol. 21, 276. https://doi.org/10.1186/s12882-020-01930-6 (2020).
Sexe, J., Mayes, C. & Tofts, P. Euglycemic diabetic ketoacidosis in a lung cancer patient using empagliflozin. Case Rep. Crit. Care 2020, 7437892. https://doi.org/10.1155/2020/7437892 (2020).
Steinmetz-Wood, S., Gilbert, M. & Menson, K. A Case of diabetic ketoacidosis in a patient on an SGLT2 inhibitor and a ketogenic diet: a critical trio not to be missed. Case Rep. Endocrinol. 2020, 8832833. https://doi.org/10.1155/2020/8832833 (2020).
Tauseef, A., Asghar, M. S., Zafar, M., Lateef, N. & Thirumalareddy, J. Sodium-glucose linked transporter inhibitors as a cause of euglycemic diabetic ketoacidosis on a background of starvation. Cureus 12, e10078. https://doi.org/10.7759/cureus.10078 (2020).
Wang, A. Y., Hou, S. K., Li, S. J. & Kao, W. F. Euglycemic diabetic ketoacidosis in type 2 diabetes with sodium glucose cotransporter 2 inhibitors. Am. J. Emerg. Med. 35(379), e375-379.e376. https://doi.org/10.1016/j.ajem.2016.08.055 (2017).
Yared, K. E. & Mancini, G. J. Euglycemic diabetic ketoacidosis associated with use of SGLT2 inhibitor after laparoscopic roux-en-Y gastric bypass. Am. Surg. https://doi.org/10.1177/0003134820940286 (2020).
Yehya, A. & Sadhu, A. Sodium-glucose cotransporter 2 inhibitor-associated prolonged euglycemic diabetic ketoacidosis in type 2 diabetes: a case report and literature review. Clin. Diabetes 38, 112–116. https://doi.org/10.2337/cd19-0035 (2020).
Yeo, S. M., Park, H., Paek, J. H., Park, W. Y., Han, S. et al. Ketoacidosis with euglycemia in a patient with type 2 diabetes mellitus taking Dapagliflozin: A case report. Medicine (Baltimore) 98, e14150. https://doi.org/10.1097/md.0000000000014150 (2019).
Bamgboye, A. O., Oni, I. O. & Collier, A. Predisposing factors for the development of diabetic ketoacidosis with lower than anticipated glucose levels in type 2 diabetes patients on SGLT2-inhibitors: a review. Eur. J. Clin. Pharmacol. https://doi.org/10.1007/s00228-020-03051-3 (2020).
Rosenstock, J. & Ferrannini, E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care 38, 1638–1642. https://doi.org/10.2337/dc15-1380 (2015).
Israel, R. S. Diabetic ketoacidosis. Emerg. Med. Clin. North Am. 7, 859–871 (1989).
Bhatt, D. L. et al. Sotagliflozin in patients with diabetes and recent worsening heart failure. New Engl. J. Medi. 384, 117–128. https://doi.org/10.1056/NEJMoa2030183 (2020).
Scheen, A. J. SGLT2 inhibitors as add-on therapy to metformin for people with type 2 diabetes: a review of placebo-controlled trials in asian versus non-asian patients. Diabetes Metab. Syndr. Obes. 13, 2765–2779. https://doi.org/10.2147/dmso.S193528 (2020).
Perry, R. J. et al. Dehydration and insulinopenia are necessary and sufficient for euglycemic ketoacidosis in SGLT2 inhibitor-treated rats. Nat. Commun. 10, 548. https://doi.org/10.1038/s41467-019-08466-w (2019).
Goldenberg, R. M. et al. SGLT2 inhibitor-associated diabetic ketoacidosis: clinical review and recommendations for prevention and diagnosis. Clin. Ther. 38, 2654-2664.e2651. https://doi.org/10.1016/j.clinthera.2016.11.002 (2016).
Yousaf, Z., Munir, W. & Hammamy, R. A. M. Use of SGLT-2 inhibitor in COVID-19: a cautionary tale. MedComm https://doi.org/10.1002/mco2.45 (2021).
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F.A.: Principal investigator, conceptualization, methodology, literature review, data collection and interpretation, manuscript writing and revision, prepared Tables 1, 2 and 3, revisions in the manuscript Z.Y.: Literature review, data collection, data analysis and interpretation, manuscript writing, prepared Tables 1, 2 and 3, Critical review, revisions in the manuscript A.K.: Literature review, data collection, and interpretation, manuscript writing, prepared Tables 1, 2 and 3, revisions in the manuscript A.R., J.A., E.A., A.A., and D.I.: Literature review, data collection, and manuscript writing M.D. and D.M.: Supervision, review, and revisions in the manuscript. All authors: Review and approval of the final manuscript.
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Ata, F., Yousaf, Z., Khan, A.A. et al. SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort. Sci Rep 11, 10293 (2021). https://doi.org/10.1038/s41598-021-89752-w
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DOI: https://doi.org/10.1038/s41598-021-89752-w
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