Endocrine Abstracts

Introduction: Dapagliflozin is an oral antidiabetic drug, recently approved for type 2 diabetes and is a sodium-glucose cotransporter type 2 inhibitor (iSGLT2). Its mechanism of action is glycosuria induction, associated with lowering glycemia. The effects of SGLT2 inhibition are insulin-independent, and efficacy is not affected by declining β-cell function or insulin resistance. Additional benefits: weight loss, reduction in blood pressure, lower incidence of hypoglycaemias. Secondary effects: diabetic ketoacidosis risk (in some cases, euglycemic ketosis), in type 2 diabetes and type 1 diabetes (in the last case, when used off-label).

Objective: To show the risk of diabetic ketoacidosis in patients treated with iSGLT2, particularly in type 1 diabetes.

Case report: A 82 years-old woman, with more than 50 years diabetes diagnosis, associated with microvascular and macrovascular complications (coronary disease, diabetic neuropathy and retinopathy); treated with insulin at the diagnosis. Classified always on type 2 diabetes. She presented at the emergency service with two days of headache, anorexia, nausea, abdominal pain. Previously, the patient had been evaluated and treated with analgesia and proton pump inhibitor. Physical examination at the emergency service: dehydration, tachycardia and abdominal pain. Laboratory findings: hyperglycaemia (556 mg/dl), acidosis (pH – 7.21, HCO3 – 9.8 mEq/l), positive ketone test (5.7 mmol/l), acute renal failure (creatinine: 1.86 mg/dl, basal creatinine 0.5 mg/dl), leucocytosis (19.3 G/L) and negative C-reactive protein. It was diagnosed a diabetic ketoacidosis and the patient was hospitalized with continuous insulin infusion and fluids. Further investigation showed recent onset of dapagliflozin (10 mg/day). Other medication: Abasaglar ® id, metformin (1000 mg 3id) and sitagliptin (50 mg 2id). Laboratory findings: haemoglobin A1c – 11.1%, c-peptide 0.2 ng/ml (1.0–7.6 ng/ml), ICA – positive, GADA – 79.81 U/ml (<1.0) and IA-2 – 0.16 U/ml (<1.0). After clinical stabilization, the patient was discharge with insulin (NovoMix 30®, 3id). Dapagliflozin and others oral antidiabetic drugs were stopped.

Discussion and conclusion: The present case pretends to show the risk of diabetic ketoacidosis in both type 1 and type 2 diabetes, particularly in type 1 diabetes. So, when hyperglycaemia and/or ketosis symptoms are present, it is essential to perform ketone test and gasometry. It is important to know that patients treated with iSGLT2, may have mild hyperglycaemia, even in diabetic ketoacidosis. This case is also intended to show that a considerable rate of patients, classified with type 2 diabetes, have effectively an autoimmune diabetes.