New Diabetic Medication Sodium-Glucose Cotransporter-2 Inhibitors Can Induce Euglycemic Ketoacidosis and Mimic Surgical Diseases: A Case Report and Review of Literature

Overview

Journal Front Surg

Specialty General Surgery

Date 2022 Apr 11

PMID 35402477

Authors

Antonia-Therese Kietaibl

Peter Fasching

Karl Glaser

Alexander H Petter-Puchner

Affiliations

Soon will be listed here.

Abstract

Background: Euglycemic diabetic ketoacidosis (EDKA) is a potentially life-threatening condition and a reported side effect of antidiabetic sodium-glucose-cotransporter-2-inhibitors (SGLT2-I). The analysis of the herein presented case and its management formed the incentive to prepare this multidisciplinary work and includes an overview about perioperative SGLT2-I-induced ketoacidosis.

Method: A PubMed search on relevant entries was conducted combining the terms "euglycemic diabetic ketoacidosis" AND "surgery."

Results: A total of 33 articles on SGLT2-I-induced ketoacidosis in the context of surgical treatment were identified. According to this literature research risk factors for the development are infection, perioperative fasting, surgical stress, and insulin dose reduction.

Conclusion: Unspecific symptoms mimicking acute abdomen and normoglycemia can lead to delayed diagnosis of EDKA and might harm patients under SGLT2-I therapy in the perioperative setting. SGLT2-I medication should be withheld for at least 24-48 h prior to surgery according to this review of literature and restarted only in stable clinical conditions to avoid the severe complication of EDKA.

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References

Milder D, Milder T, Kam P . Sodium-glucose co-transporter type-2 inhibitors: pharmacology and peri-operative considerations. Anaesthesia. 2018; 73(8):1008-1018. DOI: 10.1111/anae.14251. View

Perkovic V, Jardine M, Neal B, Bompoint S, Heerspink H, Charytan D . Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. N Engl J Med. 2019; 380(24):2295-2306. DOI: 10.1056/NEJMoa1811744. View

Jaklevic M . The Push for Earlier Bariatric Surgery for Adolescents With Severe Obesity. JAMA. 2021; 325(22):2241-2242. DOI: 10.1001/jama.2021.7912. View

Lau A, Bruce S, Wang E, Ree R, Rondi K, Chau A . Perioperative implications of sodium-glucose cotransporter-2 inhibitors: a case series of euglycemic diabetic ketoacidosis in three patients after cardiac surgery. Can J Anaesth. 2017; 65(2):188-193. DOI: 10.1007/s12630-017-1018-6. View

Somagutta M, Agadi K, Hange N, Jain M, Batti E, Emuze B . Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers. Cureus. 2021; 13(3):e13665. PMC: 8012260. DOI: 10.7759/cureus.13665. View

Qiu H, Novikov A, Vallon V . Ketosis and diabetic ketoacidosis in response to SGLT2 inhibitors: Basic mechanisms and therapeutic perspectives. Diabetes Metab Res Rev. 2017; 33(5). DOI: 10.1002/dmrr.2886. View

Bamgboye A, Oni I, Collier A . Predisposing factors for the development of diabetic ketoacidosis with lower than anticipated glucose levels in type 2 diabetes patients on SGLT2-inhibitors: a review. Eur J Clin Pharmacol. 2020; 77(5):651-657. DOI: 10.1007/s00228-020-03051-3. View

Kitahara C, Morita S, Kishimoto S, Matsuno S, Uraki S, Takeshima K . Early detection of euglycemic ketoacidosis during thoracic surgery associated with empagliflozin in a patient with type 2 diabetes: A case report. J Diabetes Investig. 2020; 12(4):664-667. PMC: 8015814. DOI: 10.1111/jdi.13365. View

Banakh I, Kung R, Gupta S, Matthiesson K, Tiruvoipati R . Euglycemic diabetic ketoacidosis in association with dapagliflozin use after gastric sleeve surgery in a patient with type II diabetes mellitus. Clin Case Rep. 2019; 7(5):1087-1090. PMC: 6509932. DOI: 10.1002/ccr3.2147. View

10.

Bteich F, Daher G, Kapoor A, Charbek E, Kamel G . Post-surgical Euglycemic Diabetic Ketoacidosis in a Patient on Empagliflozin in the Intensive Care Unit. Cureus. 2019; 11(4):e4496. PMC: 6581413. DOI: 10.7759/cureus.4496. View

11.

Burke K, Schumacher C, Harpe S . SGLT2 Inhibitors: A Systematic Review of Diabetic Ketoacidosis and Related Risk Factors in the Primary Literature. Pharmacotherapy. 2016; 37(2):187-194. DOI: 10.1002/phar.1881. View

12.

Mackintosh C, Tewari A, Siegel J, Doris Wang R, Freeman W . Postoperative Euglycemic Diabetic Ketoacidosis and Encephalopathy Related to SGLT-2 Inhibitors: A Case Report and Discussion of Diabetes Treatment and "Sweet Pee Encephalopathy" in Perioperative Hospital Management. Neurohospitalist. 2019; 10(1):51-54. PMC: 6900651. DOI: 10.1177/1941874419835035. View

13.

Wohlrab P, Kainz M, Schiferer A, Zapletal B, Tschernko E . Euglycemic Diabetic Ketoacidosis After Cardiac Surgery in a Patient Treated With Empagliflozin for Type 2 Diabetes Mellitus. J Cardiothorac Vasc Anesth. 2021; 36(7):2066-2069. DOI: 10.1053/j.jvca.2021.07.048. View

14.

Lane S, Paskar D, Hamed S, Goffi A . When Guidelines Fail: Euglycemic Diabetic Ketoacidosis After Bariatric Surgery in a Patient Taking a Sodium-Glucose Cotransporter-2 Inhibitor: A Case Report. A A Pract. 2018; 11(2):46-48. DOI: 10.1213/XAA.0000000000000734. View

15.

Nasa P, Chaudhary S, Shrivastava P, Singh A . Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes. 2021; 12(5):514-523. PMC: 8107974. DOI: 10.4239/wjd.v12.i5.514. View

16.

Heerspink H, Stefansson B, Correa-Rotter R, Chertow G, Greene T, Hou F . Dapagliflozin in Patients with Chronic Kidney Disease. N Engl J Med. 2020; 383(15):1436-1446. DOI: 10.1056/NEJMoa2024816. View

17.

Chandrashekar M, Philip S, Nesbitt A, Joshi A, Perera M . Sodium glucose-linked transport protein 2 inhibitors: An overview of genitourinary and perioperative implications. Int J Urol. 2021; 28(10):984-990. DOI: 10.1111/iju.14624. View

18.

Neal B, Perkovic V, Matthews D . Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes. N Engl J Med. 2017; 377(21):2099. DOI: 10.1056/NEJMc1712572. View

19.

Chandrakumar H, Chillumuntala S, Singh G, McFarlane S . Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy. Cureus. 2021; 13(6):e15533. PMC: 8186822. DOI: 10.7759/cureus.15533. View

20.

Packer M, Anker S, Butler J, Filippatos G, Pocock S, Carson P . Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. N Engl J Med. 2020; 383(15):1413-1424. DOI: 10.1056/NEJMoa2022190. View