Selecting Patients at Risk of Developing DKA on Gliflozins

• Published in: Journal of the Endocrine Society Vol. 5; no. Supplement_1; p. A399
• Main Author: Maletkovic, Jelena
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 03.05.2021
• Subjects: Diabetes Mellitus and Glucose Metabolism
• ISSN: 2472-1972; 2472-1972
• DOI: 10.1210/jendso/bvab048.811

Background: Since the introduction of gliflozins less than a decade ago we have witnessed how these medications are changing our approach to treating patients with type 2 diabetes mellitus. While recognizing tremendous benefits from these medication we are aware of potentially fatal risks. We present three cases of diabetic keto-acidosis in patients with type 2 diabetes mellitus and no prior history of diabetic emergencies while on SGLT2 inhibitors. Cases: A 58 year old woman with history of type 2 diabetes mellitus for 8 years and history of bulimia was treated with an SGLT2 Inhibitor for 12 months with stable control of diabetes mellitus. After an episode of very low calorie diet for 30 hours the patient was admitted to ICU with findings of diabetic ketoacidosis. She was critically ill but responded to treatment and needed only oral medication for future diabetic control. The second patient was a 49 year old man with type 2 diabetes mellitus and obesity who has been treated with oral antidiabetics for 7 years prior to requiring MDI insulin regimen in the past 3 years. The patient was well controlled in the past one year since introduction of SGLT2 inhibitors to his therapy. After a 2 day episode of eating carb heavy diet and using about 20% of prescribed insulin the patient developed DKA and was admitted to ICU where he needed to be intubated but improved and stabilized over the next few days. The third patient was a 52 year old man with history of type 2 DM for 13 years, well controlled in the past 3 years since SGLT2Is were added to his oral antidiabetic therapy. After one night of binge drinking alcohol with poor calorie intake the patient was diagnosed with DKA. After successful treatment this patient remains on oral antidiabetic medications. Conclusion: SGLT2Is have been prescribed in our clinic with great success since the first introduction of these medications. These are the only three patients who developed DKA on SGLT2 inhibitors in the past 6 years to our knowledge. All three patient had risk factors that were recognized but likely not enough emphasized. The first patient developed DKA during a “starvation phase” of eating disorder, the second one during a short episode of non-compliance with insulin while on a high carb diet and the third one after one episode of binging on alcoholic drinks. When prescribing SGLT2 inhibitors we are turning some patients with classical type 2 DM into ketosis prone diabetics. Eating disorders, extremely low or heavy carbohydrate intake, alcohol consumption and non-compliance with other antidiabetic medications should be subjects that we discuss when starting gliflozins in order to avoid significant risks. While using impressive benefits of these medications we should be aware of their side effects and recognize those that are at risk of serious side effects.