ECE2023 Poster Presentations Diabetes, Obesity, Metabolism and Nutrition (159 abstracts)
1Queens Hospital, United Kingdom; 2St Bartholomews Hospital, United Kingdom; 3Imperial College London, London, United Kingdom; 4Hialeah Hospital, Hialeah, United States
Background: SGLT-2 inhibitors (SGLT-2i) are used in treatment of type 2 diabetes mellitus (T2DM) through increasing urinary glucose secretion. Cases of euglycemic and hyperglycaemic diabetic ketoacidosis (DKA) have been reported in literature in patients using SGLT-2i. Increased glucose urinary excretion promoted by SGLT2i, decreases the production of insulin. In turn, lipolysis and ketone production increase predisposing the patient to developing DKA. It is hypothesised that SGLT2i, stimulate a cells of the pancreas, increasing the release of glucagon. The increased glucagon levels, further stimulate B-oxidation and ketone body production. In our case series we aim to describe the risk factors, demographics associated with development of SGLT-2i associated DKA and the course of disease in such patients.
Methods: All the T2DM patients with diabetic ketoacidosis on SGLT-2i who presented to the emergency department of a large hospital between Dec 26th 2018 and Jan 1st 2023 were included in the study.
Before AID Initiation | After AID Initiation | P value | |
CGM wear time,% | 81.25G16.9 | 88.44G12.71 | <0.001 |
CGM data, days | 76.39G18.8 | 81.11G16.47 | 0.002 |
Mean sensor glucose, mg/dl | 167.57G29.23 | 150.32G18.36 | <0.001 |
Glucose management indicator(GMI),% | 7.3G0.7 | 6.90G0.44 | <0.001 |
SD | 59.40G13.17 | 49.16G10.12 | <0.001 |
CV,% | 35G5 | 33G4 | <0.001 |
Time below range, <70 mg/dl(TBR),% | 3.23G3.33 | 1.97G1.98 | <0.001 |
Time between 54-70 mg/dl(TBR2),% | 0.65G1.03 | 0.36G0.5 | <0.001 |
Time below 54 mg/dl(TBR1),% | 2.58G2.39 | 1.62G1.52 | <0.001 |
Time in range, 70-180 mg/dl(TIR),% | 58.95G17.29 | 73.56G11.66 | <0.001 |
Time above range, >180 mg/dl(TAR),% | 37.81G18.29 | 24.47G12.18 | <0.001 |
Time between 181-250 mg/dl,(TAR1),% | 24.99G8.92 | 18.87G7.75 | <0.001 |
Time above 250 mg/dl(TAR2),% | 12.83G11.26 | 5.60G5.15 | <0.001 |
GRI | 48.66G21.81 | 29.01G13.01 | <0.001 |
GRI-Hypoglycemia component | 2.72G2.85 | 1.65G1.68 | <0.001 |
GRI-Hyperglycemia component | 25.32G14.52 | 15.03G8.52 | <0.001 |
Results: Ten patients were included in the study. Patient demographics are summarised in Table 1. All patients had confirmed T2DM, with negative GAD and anti-islet antibodies. Five patients were taking Canagliflozin, four-Empagliflozin, one-Dapagliflozin. Mean blood ketone level on admission was 4.18 mmol/l (2 St.Dev. ±0.274) and venous blood gas pH was 7.088 (2 St. Dev. ±0.155). Blood glucose on admission ranged from (4.7 to 28 mmol/l). Most common symptom at presentation was vomiting (n=5). Other common symptoms at presentation were abdominal pain (n=2), shortness of breath (n=2) and lethargy (n=2). Four patients had concurrent illness at presentation: urosepsis, recent knee surgery, community acquired pneumonia and acute coronary syndrome. All patients were treated with sliding scale, 1 patient was transferred to ITU, 1 required HDU support and 1 passed away from a cardiac arrest in ED. Mean duration of hospital stay was 5.3 days (2 St. Dev: 2.46 days).
Discussion: Diabetic ketoacidosis secondary to SGLT2i is a known side effect. In our cohort, we found 3 patients presenting with hyperglycaemia. DKA with SGLT2i is not uncommon, especially with intercurrent illness. Therefore patients on this therapy should be encouraged to monitor their blood ketone levels even if their blood glucose levels are within range.