Can euglycemic diabetic ketoacidosis caused by SGLT2 inhibitors be avoided in COVID-19 and other acute infections?
  • Georgios Pilianidis
    Diabetes Clinic, G. Papanikolaou General Hospital, Thessaloniki, Greece; Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece
  • Georgia Papanastasiou
    Diabetes Clinic, G. Papanikolaou General Hospital, Thessaloniki, Greece; Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece
  • Pinelopi Tikoudi
    Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece
  • Andreas Themistocleous
    Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece
  • Georgios Farmakis
    Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece
  • Konstantinos Dolianitis
    Diabetes Clinic, G. Papanikolaou General Hospital, Thessaloniki, Greece; Internal Medicine Department, G. Papanikolaou General Hospital, Thessaloniki, Greece

Keywords

COVID-19, diabetic ketoacidosis, euglycemic, SGLT-2 inhibitors

Abstract

Introduction: We present a case of anion gap euglycemic diabetic ketoacidosis (EuDKA) in a patient with COVID-19 infection. Patients with diabetes mellitus are at increased risk of severe illness, and hyperglycaemia is associated with higher morbidity and mortality in patients infected with COVID-19.
Case Description: A 76-year-old male with diabetes mellitus treated with SGLT2 inhibitor tested positive for COVID-19 infection on day 3 after his admission. In the emergency room he had a high anion gap metabolic acidosis and a blood glucose of 248 mg/dl. His urine tested strongly positive for ketones. A diagnosis of euglycemic diabetic ketoacidosis was made and he was treated with intravenous insulin and normal saline; his antidiabetic medications were stopped. His metabolic acidosis gradually resolved, and he was discharged.
Discussion: Euglycemic diabetic ketoacidosis is a rare complication of COVID-19 infection. It is defined by the American Diabetes Association as the triad of anion gap metabolic acidosis with arterial pH <7.3, serum bicarbonate <18 mmol/l and ketonuria or ketonemia. It is a life-threatening complication which usually occurs in type 1 diabetes mellitus patients but may also occur in type 2 diabetes mellitus patients. As described earlier, it is associated with hyperglycaemia but if blood glucose is low or near normal but <250 mg/dl it is then named euglycemic diabetic ketoacidosis. Patients treated with SGLT2 inhibitors are at increased risk of euglycemic diabetic ketoacidosis.
Conclusions: COVID-19 infection precipitated euglycemic diabetic ketoacidosis in our patient. SGLT2 inhibitors must be stopped when this adverse reaction occurs. As their use increases, the risk of this adverse reaction is higher as well. Their prescription should be restricted to trained physicians who are able to educate their patients and treat them appropriately in situations that may arise.

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References

  • Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr 2020;14:303–310.
  • Liu J, Li L, Li S, Wang Y, Qin X, Deng K, et al. Sodium-glucose co-transporter-2 inhibitors and the risk of diabetic ketoacidosis in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes Obes Metab 2020;22:1619–1627.
  • Douros A, Lix LM, Fralick M, Dell’Aniello S, Shah BR, Ronksley PE, et al. Sodium-glucose cotransporter-2 inhibitors and the risk for diabetic ketoacidosis: a multicenter cohort study. Ann Intern Med 2020;173:417–425.
  • Limenta M, Ho CSC, Poh JWW, Goh S-Y, Toh DSL. Adverse drug reaction profile of SGLT2 inhibitor-associated diabetic ketosis/ketoacidosis in Singapore and their precipitating factors. Clin Drug Investig 2019;39:683–690.
  • Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium–glucose cotransporter 2 inhibition. Diabetes Care 2015;38:1687–1693.
  • Secinaro E, Ciavarella S, Rizzo G, Porreca E, Vitacolonna E. SGLT2-inhibitors and euglycemic diabetic ketoacidosis in COVID-19 pandemic era: a case report. Acta Diabetol 2022;59:1391–1394.
  • Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care 2015;38:1638–1642.
  • Palermo NE, Gianchandani RY, McDonnell ME. Stress hyperglycemia during surgery and anesthesia: pathogenesis and clinical implications. Curr Diab Rep 2016;16:33.
  • Yang JK, Lin S-S, Ji X-J, Guo L-M. Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes. Acta Diabetol 2010;47:193–199.
  • Vitale RJ, Valtis YK, McDonnell ME, Palermo NE, Fisher NDL. Euglycemic diabetic ketoacidosis with COVID-19 infection in patients with type 2 diabetes taking SGLT2 inhibitors. AACE Clin Case Rep 2021;7:10–13.
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    Published: 2024-02-02
    Issue: 2024: Vol 11 No 3 (view)


    How to cite:
    1.
    Pilianidis G, Papanastasiou G, Tikoudi P, Themistocleous A, Farmakis G, Dolianitis K. Can euglycemic diabetic ketoacidosis caused by SGLT2 inhibitors be avoided in COVID-19 and other acute infections?. EJCRIM 2024;11 doi:10.12890/2024_004282.