[Diabetic Euglycemic Ketosis or Ketoacidosis in Individuals with Type 2 Diabetes Treated by SGLT2 Inhibitors: A Series of Belgian Clinical Cases]

Introduction: Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) are new therapeutic agents that improves the management of type 2 diabetes. Clinical trial results for SGLT2i have shown a reduction in blood glucose levels and a decrease in significant cardiovascular and renal complications related to diabetes. However, rare adverse events such as diabetic ketoacidosis have been reported in these clinical trials and in "real life". These ketoacidosis were atypical because the hyperglycemia was less severe than in traditional acute diabetes, hence the name of "euglycemic" ketoacidosis. We detail a series of local cases associated with the use of SGLT2i in type 2 diabetic patients.

Methods: This was a retrospective consecutive case study, with a review of medical records from 2016 to 2019. We identified 7 single episodes of "euglycemic" ketoacidosis associated with SGLT2i use in individuals with type 2 diabetes.

Results: Seven cases of type 2 diabetic individuals (M/F: 5/2) aged from 51 to 74years old were analysed. All had symptoms of hyperketonemia (fruity smelling breath, nausea or lack of appetite) and an increase level of capillary β-hydroxybutyric acid despite a glycaemia between 112 and 280mg/dL. The risk factors for ketoacidosis identified in these patients were: prolonged fasting, infection, dehydration and significantly decreased in insulin secretory function (according to the HOMA model), revealing endogenous insulinopenia before ketoacidosis.

Conclusion: The increasing use of SGLT2i in individuals with type 2 diabetes is likely to increase the number of ketoacidosis cases. It is essential to recognise this complication and prevent it according to each patient's risk factors.