Steinmetz-Wood Samantha, Gilbert Matthew, Menson Katherine
Department of Medicine, Larner College of Medicine at the University of Vermont, 111 Colchester Ave, Burlington, VT, USA.
Case Rep Endocrinol. 2020 Aug 13;2020:8832833. doi: 10.1155/2020/8832833. eCollection 2020.
Results from major clinical trials have shown significant cardiorenal-protective benefits of SGLT2 inhibitors in patients with type 2 diabetes (T2DM), leading to increased popularity. A rare but serious side effect of SGLT2 inhibitors is euglycemic diabetic ketoacidosis (EDKA), which presents more covertly but has been described. Identification and report of modifiable risk factors would be an important step in helping clinicians appropriately counsel patients. In this case report, we present DKA in a patient on an SGLT2 inhibitor and ketogenic diet (KD). A 47-year-old male with a history of poorly controlled T2DM on metformin and empagliflozin presented to the emergency department (ED) with several days of pharyngitis, dyspnea, emesis, abdominal pain, and anorexia. Of note, one month prior to this event, he presented to the ED with malaise and was found to have an anion gap of 21, a bicarbonate level of 13 mmol/L, a pH level of 7.22, 3+ ketonuria, and a glucose level of 7 mmol/L (127 mg/dl). Additional workup was negative, and findings were attributed to his KD. His use of empagliflozin was not identified on his medication list. At second presentation, the patient was tachypneic and tachycardic and had mild abdominal tenderness. Labs revealed anion gap 28, bicarbonate 5 mmol/l, pH 6.94, 3+ ketonuria, glucose 14.9 mmol/L (269 mg/dl), and beta-hydroxybutyrate 8.9 mmol/L. The patient was diagnosed with DKA and was treated accordingly. With closure of anion gap, the patient was transitioned to insulin and metformin, and his empagliflozin was discontinued indefinitely. Before prescribing this medication class, physicians should inquire about low-carbohydrate diets given the higher risk for DKA, though knowledge of this risk is still not widespread.
大型临床试验结果表明，钠-葡萄糖协同转运蛋白2（SGLT2）抑制剂对2型糖尿病（T2DM）患者具有显著的心肾保护益处，因此其使用日益普遍。SGLT2抑制剂一种罕见但严重的副作用是正常血糖性糖尿病酮症酸中毒（EDKA），其表现更为隐匿，但已有相关描述。识别并报告可改变的风险因素将是帮助临床医生为患者提供适当建议的重要一步。在本病例报告中，我们介绍了一名服用SGLT2抑制剂并采用生酮饮食（KD）的患者发生糖尿病酮症酸中毒（DKA）的情况。一名47岁男性，有二甲双胍和恩格列净治疗的T2DM控制不佳病史，因咽痛、呼吸困难、呕吐、腹痛和厌食数天就诊于急诊科（ED）。值得注意的是，在此次事件发生前一个月，他因不适就诊于ED，发现阴离子间隙为21，碳酸氢盐水平为13 mmol/L，pH值为7.22，尿酮体3+，血糖水平为7 mmol/L（127 mg/dl）。进一步检查结果为阴性，检查结果归因于他的KD。在他的用药清单上未发现他使用恩格列净。在第二次就诊时，患者呼吸急促、心动过速，有轻度腹部压痛。实验室检查显示阴离子间隙28，碳酸氢盐5 mmol/l，pH 6.94，尿酮体3+，血糖14.9 mmol/L（269 mg/dl），β-羟丁酸8.9 mmol/L。该患者被诊断为DKA并接受相应治疗。随着阴离子间隙的闭合，患者改用胰岛素和二甲双胍，其恩格列净被无限期停用。鉴于DKA风险较高，医生在开具这类药物之前应询问患者是否采用低碳水化合物饮食，不过这种风险的认知仍不普遍。
