Lee In Hee, Ahn Dong Jik
Department of Internal Medicine, Daegu Catholic University School of Medicine.
Department of Internal Medicine, Hansung Union Internal Medicine Clinic and Dialysis Center, Daegu, Republic of Korea.
Medicine (Baltimore). 2020 May 22;99(21):e20228. doi: 10.1097/MD.0000000000020228.
Rare cases of euglycemic diabetic ketoacidosis (eu-DKA) have been reported after the administration of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. No reports have described eu-DKA complicated by hypernatremia due to SGLT-2 inhibitors.
A 76-year-old woman with a 40-year history of type 2 diabetes mellitus (DM), for which metformin (1000 mg/day) and dapagliflozin (10 mg/day) were prescribed, presented with malaise, fever, and oliguria. On presentation, her white blood cell count (11,800/μL), serum creatinine (3.2 mg/dL), and C-reactive protein (54 mg/L) were abnormal. Bilateral pyeloureteritis and diffuse paralytic ileus were present. She received intravenous antibiotics and total parenteral nutrition, and was asked to fast. Her renal function and ileus briefly improved. Oral hypoglycemic agents, metformin and dapagliflozin, along with enteral feeding were reinstituted on day 3 of hospitalization. However, on day 6 of hospitalization, the patient developed an altered state of consciousness including confusion, lethargy, and stupor. Several laboratory abnormalities suggestive of ketoacidosis with euglycemia were noted.
The patient was diagnosed with eu-DKA accompanied by severe hypernatremia (corrected serum Na concentration, 163 mEq/L) and hypokalemia following dapagliflozin re-administration.
The patient was treated with indicated intravenous fluid therapy. Dapagliflozin use was discontinued.
The patient's mental status and laboratory findings improved gradually, and she was discharged on maintenance doses of insulin and metformin on day 14 of hospitalization.
Acute illnesses such as diffuse paralytic ileus and urinary tract infection, and dietary restrictions or fasting in patients with DM can be considered potential predisposing factors for SGLT-2 inhibitor-associated eu-DKA. For patients with diabetes in the setting of acute morbidity, timely resumption of the SGLT-2 inhibitor therapy should be carefully determined. In addition, eu-DKA due to SGLT-2 inhibitor use may be accompanied by electrolyte disturbances such as hypernatremia and hypokalemia.
已有报道称，在使用钠-葡萄糖协同转运蛋白2（SGLT-2）抑制剂后出现了罕见的正常血糖性糖尿病酮症酸中毒（eu-DKA）病例。尚无关于SGLT-2抑制剂导致eu-DKA并发高钠血症的报道。
一名76岁女性，有40年2型糖尿病病史，正在服用二甲双胍（1000毫克/天）和达格列净（10毫克/天），出现不适、发热和少尿症状。就诊时，她的白细胞计数（11,800/μL）、血清肌酐（3.2毫克/分升）和C反应蛋白（54毫克/升）异常。存在双侧肾盂输尿管炎和弥漫性麻痹性肠梗阻。她接受了静脉抗生素治疗和全胃肠外营养，并被要求禁食。她的肾功能和肠梗阻症状短暂改善。住院第3天重新开始使用口服降糖药二甲双胍和达格列净以及肠内营养。然而，住院第6天，患者出现意识状态改变，包括意识模糊、嗜睡和昏迷。发现了一些提示正常血糖性酮症酸中毒的实验室异常。
重新使用达格列净后，患者被诊断为eu-DKA，伴有严重高钠血症（校正血清钠浓度为163毫当量/升）和低钾血症。
对患者进行了指定的静脉补液治疗。停用达格列净。
患者的精神状态和实验室检查结果逐渐改善，住院第14天出院时使用胰岛素和二甲双胍维持剂量。
弥漫性麻痹性肠梗阻和尿路感染等急性疾病，以及糖尿病患者的饮食限制或禁食，可被视为SGLT-2抑制剂相关eu-DKA的潜在诱发因素。对于患有急性疾病的糖尿病患者，应谨慎确定是否及时恢复SGLT-2抑制剂治疗。此外，使用SGLT-2抑制剂导致的eu-DKA可能伴有高钠血症和低钾血症等电解质紊乱。
