Endocrine Abstracts

Introduction: LADA (Latent autoimmune diabetes in adults) is an adult-onset and more indolent variety of autoimmune type 1 diabetes mellitus. In autoimmune diabetes, younger individuals typically have a rapid rate of beta-cell destruction and usually present with ketoacidosis, while adults often maintain sufficient insulin secretion to prevent ketoacidosis for many years. LADA is usually misdiagnosed initially as type 2 diabetes due to its late onset but LADA patients are antibody positive and often require insulin therapy within years of diagnosis. We presented a resistant diabetic ketoacidosis case requiring hemodialysis for long-lasting acidosis after starting dapagliflozin in a patient with LADA formerly misdiagnosed as type 2 diabetes.

Case report: A 54-year-old over-weight white woman who had been followed for her euthyroid autoimmune thyroiditis and type 2 diabetes mellitus for 3 years was admitted to our endocrinology out-patient clinics. During another 3-year period she was followed by intensive insulin regimen plus metformin but after initiating a strict diet programme, she had experienced postprandial hypoglycemia episodes on 3×6 units glulisine and 1×10 units glargine insulin. Her glulisine insulin was stopped and dapagliflozin was added to metformin and glargine. At the fourth day of her new treatment, she returned to our emergency department in the state of severe diabetic ketoacidosis (DKA) [glucose 414 mg/dl, arterial pH: 6.82, lactate 4.2 mmol/l, HCO₃: 4.9 mmol/l, pCO₂: 19.8 mmHg, at urinalysis ketonuria (3+), glucosuria (1+)]. İntravenous hydration, insulin infusion, potassium replacement were initiated at our intensive care unit. After 72 hour of her treatment, ketoacidosis was still severe and due to the failure of intravenous bicarbonate treatment also in correcting acidosis, hemodialysis was started. After 3 sessions of hemodialysis, acidosis was relieved and this resistant ketoacidosis treatment could be changed to subcutaneous intensive insulin regimen only at the 8^th day of ICU. Metformin and dapagliflozin were not given anymore and she was discharged at the 13^th day of admission with intensive insulin regimen. Due to this resistant DKA status, pancreatic islet antibodies were assessed and two of them were measured as positive [Anti-GAD: 3,58 U/ml (reference range: 0-1), ICA was positive]. The diagnosis of the patient were re-evaluated as LADA.

Conclusion: LADA should be kept in mind in adults with diabetes and another autoimmune disease. And gliflozins can cause euglycemic diabetic ketoacidosis especially when the insulin treatment regimen was loosened in intensity in these misdiagnosed patients.