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A Can’t Miss ED Diagnosis: Euglycemic DKA

2018-03-22T16:08:10+00:00

A middle-aged man with a history of diabetes and hypertension presents with nausea, vomiting, and shortness of breath. His laboratory testing is remarkable for a leukocytosis, ketonemia, and an anion gap acidosis (pH of 7.13). The EM resident caring for this patient is surprised to find that the blood glucose is 121 mg/dL.

Which home medication is likely responsible for this presentation?

  1. Metformin
  2. Glipizide
  3. Liraglutide
  4. Canagliflozin


Reveal the Answer
1.
Cefalu W, Leiter L, Yoon K, et al. Efficacy and safety of canagliflozin versus glimepiride in patients with type 2 diabetes inadequately controlled with metformin (CANTATA-SU): 52 week results from a randomised, double-blind, phase 3 non-inferiority trial. Lancet. 2013;382(9896):941-950. [PubMed]
2.
Tikkanen I, Narko K, Zeller C, et al. Empagliflozin reduces blood pressure in patients with type 2 diabetes and hypertension. Diabetes Care. 2015;38(3):420-428. [PubMed]
3.
Handelsman Y, Henry R, Bloomgarden Z, et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THE ASSOCIATION OF SGLT-2 INHIBITORS AND DIABETIC KETOACIDOSIS. Endocr Pract. 2016;22(6):753-762. [PubMed]
4.
FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. U.S. Food and Drug Administration: Drug and Safety Availability. https://www.fda.gov/Drugs/DrugSafety/ucm475463.htm. Published January 19, 2018. Accessed March 18, 2018.
5.
Munro J, Campbell I, McCuish A, Duncan L. Euglycaemic diabetic ketoacidosis. Br Med J. 1973;2(5866):578-580. [PubMed]
6.
Kitabchi A, Umpierrez G, Miles J, Fisher J. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343. [PubMed]
7.
Rosenstock J, Ferrannini E. Euglycemic Diabetic Ketoacidosis: A Predictable, Detectable, and Preventable Safety Concern With SGLT2 Inhibitors. Diabetes Care. 2015;38(9):1638-1642. [PubMed]
8.
Ogawa W, Sakaguchi K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. J Diabetes Investig. 2016;7(2):135-138. [PubMed]
9.
European Medicines Agency. SGLT2 Inhibitors-Scientific Conclusions. European Medicines Agency; 2016:2-4. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/SGLT2_inhibitors__20/European_Commission_final_decision/WC500206487.pdf. Accessed February 1, 2018.
10.
Peters A, Buschur E, Buse J, Cohan P, Diner J, Hirsch I. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care. 2015;38(9):1687-1693. [PubMed]
Theresa Kim, MD

Theresa Kim, MD

Toxicology Fellow, The Toxikon Consortium
Attending Physician
Department of Emergency Medicine
Cook County Health and Hospitals System
Theresa Kim, MD

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