Endocrine Abstracts

Diabetic Ketoacidosis (DKA) in patients with Type 2 Diabetes Mellitus (T2DM) is relatively rare and usually associated with intercurrent illness but can cause significant morbidity and mortality. SGLT2 inhibitor (SGLT2i) use has been implicated as a potential risk factor for developing euglycaemic DKA, particularly in sepsis, surgery and starvation. We aimed to investigate the common causes of DKA in T2DM in NHS Lothian to identify whether SGLT2i use was having a significant impact. We retrospectively reviewed casenotes for T2DM patients admitted with DKA to the Royal Infirmary of Edinburgh and Western General Hospital in 2020-21. Demographic and biochemical data was collected and notes were reviewed for precipitants and relevant medication. 69 T2DM patients were admitted with DKA. Common precipitants included infections, insulin omission and alcohol. 43% were on regular SGLT2i treatment with 26.6% first prescribed in the preceding six months. Patients on SGLT2i had lower glucose levels (median 15.65 vs 30.5mmol/l), higher ketones (median 5.2 vs 5.0mmol/l) and more severe acidosis (median H+ 72.9 vs 56nmol/l). C-peptide was measured in 49.3% of patients on SGLT2i with median level 621 pmol/l. Only 17% had documentation of sick day rules in clinical letters. Just under half of all recorded DKA episodes in T2DM were associated with SGLT2i therapy. Patients were more acidotic, ketotic and had lower blood glucose levels. This may simply reflect increasing prescription of these drugs but raises the possibility that the threshold for DKA is lowered. We have highlighted the importance of regular discussion of sick day rules in clinic along with providing patient information leaflets. We have liaised with primary care to ensure these alerts are clear on community prescriptions. Finally, we have used our electronic prescribing system to include an alert to prescribers to consider SGLT2i suspension for patients admitted with acute illnesses or for major surgery.