Brief ObservationBeware Ketoacidosis with SGLT2 Inhibitors in Latent Autoimmune Diabetes of the Adult
Section snippets
Patient 1
A 56-year-old woman presented to the hospital with a 3-day history of nausea, vomiting, and confusion. She had a history of type 2 diabetes, Hashimoto's thyroiditis, and morbid obesity (body mass index [BMI]=44.6 kg/m2) and had undergone sleeve gastrectomy 1 year prior, resulting in 42 kg weight loss (BMI 27.5 kg/m2). Medications at presentation were metformin XR 1000 mg, gliclazide MR 60 mg, empagliflozin 10 mg, rosuvastatin 20 mg, and thyroxine 100 mcg. Blood glucose was raised at 22 mmol/L,
Patient 2
A 68-year-old woman, with a history of presumed type 2 diabetes, was admitted to the hospital with severe euglycemic ketoacidosis (Table 1). She was diagnosed with diabetes at age 53, after presenting with symptomatic hyperglycemia, and was commenced on insulin within 12 months of diagnosis. Her BMI was 23 kg/m2 at diagnosis. Three months prior to presentation, metformin and empagliflozin was commenced, and mixed insulin (NovoMix 30, Novo Nordisk, Bagsvaerd, Denmark), 12 units twice daily, was
Patient 3
A 60-year-old man, with a known history of latent autoimmune diabetes of the adult, was transferred to a metropolitan hospital in severe diabetic ketoacidosis (Table 1). He was usually treated with mixed insulin (NovoMix 30), 30 units twice daily; metformin 2000 mg daily; and dapagliflozin 10 mg daily. Two days prior to presentation, he had developed a gastrointestinal illness and had withheld insulin and oral hypoglycemic agents for 24 hours in the setting of reduced oral intake. The patient
Discussion
The American Association of Clinical Endocrinologists and American College of Endocrinology position statement acknowledges that SGLT2 inhibitor-associated ketoacidosis is most common in patients with insulin deficiency, including patients with latent autoimmune diabetes of the adult, type 1 diabetes, and long-standing type 2 diabetes.13 A case series of patients enrolled in the canagliflozin randomized controlled trials, demonstrated that 6 out of 12 patients who presented with diabetic
References (18)
- et al.
American Association of Clinical Endocrinologists and American College of Endocrinology position statement on the association of SGLT-2 inhibitors and diabetic ketoacidosis
Endocr Pract
(2016) - et al.
Management of Hyperglycemia in Type 2 Diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)
Diabetes Care
(2018) - et al.
Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes
N Engl J Med
(2015) - et al.
Canagliflozin and cardiovascular and renal events in type 2 diabetes
N Engl J Med
(2017) - et al.
Dapagliflozin and cardiovascular outcomes in type 2 diabetes
N Engl J Med
(2019) - et al.
Dapagliflozin in patients with heart failure and reduced ejection fraction
N Engl J Med
(2019) - et al.
Empagliflozin and progression of kidney disease in type 2 diabetes
N Engl J Med
(2016) - et al.
Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition
Diabetes Care
(2015) - et al.
Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors
Diabetes Care
(2015)
Cited by (2)
Latent Autoimmune Diabetes in Adults (LADA) - Clinical Features
2021, Journal of Internal Medicine of Taiwan
Funding: None.
Conflict of Interest: None.
Authorship: All authors had access to the data and a role in writing this manuscript.