Diabetic Ketoacidosis Linked with Sodium Glucose Co-Transporter 2 Inhibitors in an Elderly Patient with Type 2 Diabetes

Abstract

Objective: To report an episode of diabetic ketoacidosis and acute kidney failure in a patient with type 2 diabetes (T2DM) recently initiated a sodiumglucose co-transporter 2 inhibitor (SGLT-2i) and a DDPP-4 inhibitor (DDP-4i). Methods: We describe the clinical presentation, laboratory data and management of an elderly T2DM patient with diabetic ketoacidosis. Results: A 80 year-old T2DM female presented with, fatigue, nausea, recurrent vomiting, muscle pain, malaise and shortness of breath three weeks after initiation of dapagliflozin 5 mg and sitagliptin 100 mg. On admission to the emergency department, the patient was hypotensive, and rapidly became comatose. The glucose concentration was 398 mg/dL, Na 135 mmol/L, K 4.1 mmol/L, pH 6.8, and bicarbonate 1.8 mmol/L, blood urea nitrogen 22.8 mg/dL, creatinine 0.96 mg/dL, beta-hydroxybutirate 3.2 mmol/L and lactate 1.1 mmol/L. The estimated osmolality was 300.25 mOsm/L and the anion gap 26.7 mEq/L. C-reactive protein was <2.5 mg/L. Urine sample was normal and urine culture was negative. Hemoglobin was 12.6 g/dL; leucocyte count was 21.0 × 103 μL and platelet count 253 × 103 μL. Two days after hospitalisation the patient developed an acute kidney failure and anemia. The patient was treated with balanced electrolyte solutions, continuous insulin infusion and IV antibiotics and dapagliflozin was discontinued. Diabetic ketoacidosis resolved in 48 hours and the acute kidney failure in 6 days. The patient was discharged 10 days after admission with a basal bolus regimen with insulin analogues. Conclusions: This elderly patient with long lasting type 2 diabetes treated with SGLT-2i developed diabetic ketoacidosis and acute kidney failure. This complication occurred associated with dietary derangements and lack of insulin treatment. Each medication change needs a very clear indication; otherwise it adds more risk to the patient than benefit. When prescribing SGLT2i in diabetics, physician must assure diabetes education, an adequate insulin provision and strict monitoring of glucose and urine ketones.