Critical Care: Fellow Case Report Slide: Critical Care II |

SGLT2 Inhibitors: Mind the Gap FREE TO VIEW

Chuan Jiang, MD; Atul Palkar, MBBS; Jonathan Caronia, MD; Eric Gottesman, MD
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Hofstra-Northwell School of Medicine, New Hyde Park, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):266A. doi:10.1016/j.chest.2016.08.279
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SESSION TITLE: Fellow Case Report Slide: Critical Care II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 25, 2016 at 07:30 AM - 08:30 AM

INTRODUCTION: Sodium Glucose Co-transporter 2 (SGLT2) inhibitors are being increasingly prescribed for Type 2 diabetes mellitus (DM). Our case describes euglycemic diabetic ketoacidosis (DKA) in a patient with Type 1 DM in the setting of SGLT2 inhibitor use.

CASE PRESENTATION: A 20-year old woman presented with polydipsia, anorexia and a blood glucose level of 300 mg/dL on her home blood glucose monitor. She had type 1 DM controlled on insulin pump for the past 10 years. Two weeks prior to admission she was started on Canagliflozin, an oral SGLT2 inhibitor. She was admitted with DKA, anion gap of 29 mmol/dL and serum glucose of 289 mg/dL. Insulin pump was discontinued and she was initiated on insulin infusion. Within 12 hours, anion gap closed and she was transitioned to long acting insulin. However, DKA relapsed within 1 day. She had no precipitating factors for DKA except persistent heavy glycosuria. We hypothesized that she had insulin deficiency despite near normal blood glucose level likely due to persistent glycosuria as a result of ongoing SGLT2 inhibition and impaired glucose reabsoprtion in the proximal renal tubules. She was subsequently initiated on higher insulin infusion with 10 % Dextrose infusion to allow metabolism of ketones and prevent hypoglycemia. She required insulin infusion for 4 days before closure of anion gap. Large level of glycosuria persisted for 7 days before showing a declining trend. She was discharged on subcutaneous insulin regimen.

DISCUSSION: SGLT2 inhibitors promote weight loss and may have cardiovascular benefits. While SGLT2 use may be feasible1, no randomized trials have established their efficacy or safety in Type 1 DM. SGLT2 use in T2 DM precipitating euglycemic DKA is well described.2 DKA in the setting of SGLT2 inhibitor use may be diagnosed late due to relatively normal blood glucose level. Insulin infusion may be required at a higher dose and for prolonged periods with dextrose infusion due to continued glycosuria and relative normoglycemia.

CONCLUSIONS: With recent popularity of this drug class, physicians should be aware of refractory euglycemic DKA and persistent glycosuria precipitated by SGLT2 inhibitors.

Reference #1: Henry RR, et al. Exploring the Potential of the SGLT2 Inhibitor Dapagliflozin in Type 1 Diabetes: A Randomized, Double Blind, Placebo-Controlled Pilot Study. Diabetes Care 2015; 38:412-419.

Reference #2: Hayami T, et al. Case of ketoacidosis by a SGLT2 inhibitor in a diabetic patient with a low carbohydrate diet. Journal of Diabetes Investigation 2015; 6:587-590.

DISCLOSURE: The following authors have nothing to disclose: Chuan Jiang, Atul Palkar, Jonathan Caronia, Eric Gottesman

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