Euglycemic Diabetic Ketoacidosis in a Patient with Type 2 Diabetes After

Diabetes Care Volume 39, January 2016 e3

Euglycemic Diabetic Ketoacidosis in a Paris Roach and Paul Skierczynski Patient With Type 2 Diabetes After Treatment With Empagliflozin Diabetes Care 2016;39:e3 | DOI: 10.2337/dc15-1797

Sodium–glucose cotransporter 2 (SGLT2) the next day. She had had only one alco- type 1 diabetes or had latent autoimmune inhibitors have been associated with holic drink between starting empagliflozin diabetes of adulthood. The patient report- euglycemic diabetic ketoacidosis (eDKA). andpresentingtotheER. ed here had type 2 diabetes diagnosed on All reports to date have involved canagli- Laboratory evaluation in the ER clinical grounds. She had a history of ges- flozin (Invokana; Janssen Pharmaceuti- showed CO2 of 11 mmol/L, anion gap tational diabetes mellitus followed by the cals), with the exception of one case of 21 mEq/L, and blood glucose of 161 diagnosis of diabetes 5 years later and the associated with ipragliflozin (1). It has mg/dL. Over the next 4–6h,CO2 fell to 6 initiation of insulin 5 years after diagnosis. been anticipated that eDKA is a class effect, mmol/L, anion gap increased to 24 mEq/L, Her BMI was 36.5 kg/m2, she was poorly but no case reports of eDKA with other and nausea and vomiting developed. controlled while taking 140 units of insulin SGLT2s have been reported. Here, we Having been informed of the risk of DKA daily (;1 unit per kg), and her blood glu- report a case of eDKA in a patient with with empagliflozin, she asked that her cosehadbeenmaintainedinthelow200 type 2 diabetes treated with empagliflozin. endocrinologist be consulted. He was mg/dL range on liraglutide alone for 3 A 64-year-old woman with a 15-year suspicious of eDKA and suggested a weeks. In conclusion, this is the first report history of type 2 diabetes and a 5-day measurement of serum ketones. of eDKA during treatment with empagliflo- history of treatment with empagliflozin b-Hydroxybutyrate was found to be zin, further indicating that eDKA is a class (Jardiance; Boehringer Ingelheim) pre- 8.22 mmol/L (normal up to 0.27 mmol/L), effect and that patients with type 2 diabe- sented to the emergency room (ER) for and arterial pH was 7.07. Venous lactate tes may develop eDKA during treatment evaluation of shortness of breath. She was normal. She was treated with intrave- with SGLT2 inhibitors. had been treated with insulin for 10 nous fluids, insulin, and glucose, and the – years. At the time she started empagli- eDKA resolved over 24 36 h. Duality of Interest. No potential conflicts flozin, she was taking liraglutide 1.8 mg This is the first report of eDKA during of interest relevant to this article were reported. per day. She had been taking NPH 40 treatment with empagliflozin. Potential Author Contributions. P.R. and P.S. were both involved in the care of this patient during the units twice daily and regular insulin 20 risk factors based on previous reports in- e-LETTERS units with meals but had independently clude recent discontinuation of insulin and reportedeventandcontributedtothecontent of this report. P.R. is the guarantor of this work and, discontinued insulin 3 weeks prior to alcohol intake. In a recent case series of as such, had full access to all the data in the study presentation to determine if her blood eDKA associated with canagliflozin, two pa-

and takes responsibility for the integrity of the – glucose could be controlled with liraglu- tients with type 2 diabetes developed data and the accuracy of the data analysis. OBSERVATIONS tide alone. Capillary glucose measure- eDKA in the postoperative setting (1). A References ments were in the low 200 mg/dL range recent analysis of eDKA in the canagliflozin 1. Peters AL, Buschur EO, Buse JB, Cohan P, on liraglutide alone, so treatment with em- clinical trial program indicated that the in- Diner JC, Hirsch IB. Euglycemic diabetic ketoaci- pagliflozin 10 mg per day was initiated. cidence of DKA in people with type 2 di- dosis: a potential complication of treatment Within 24 h of starting empagliflozin, she abetes treated with canagliflozin was with sodium-glucose cotransporter 2 inhibition. developed symptoms of weakness, joint comparable to that of the general popula- Diabetes Care 2015;38:1687–1693 2. Erondu N, Desai M, Ways K, Meininger G. pain, and mild confusion. After 4 days of tion (2). The authors commented that most Diabetic ketoacidosis and related events in the treatment, she began to experience dysp- subjects had precipitating factors for DKA canagliflozin type 2 diabetes clinical program. nea on exertion and presented to the ER or possibly had been misdiagnosed with Diabetes Care 2015;38:1680–1686

Division of Endocrinology, Indiana University School of Medicine, Indianapolis, IN Corresponding author: Paris Roach, [email protected]. Received 17 August 2015 and accepted 21 September 2015. © 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.