Euglycaemic DKA in a patient with LADA after treatment with empagliflozin. — ASN Events
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Euglycaemic DKA in a patient with LADA after treatment with empagliflozin. (#240)

Nishant Nundlall 1 , Soji Swaraj 1 , Bronwyn A Crawford 1 2
  1. Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW , Australia
  2. Concord Clinical School, Sydney Medical School, The University of Sydney, Concord, NSW

A 47 yr old man with known diabetes presented with euglycaemic ketoacidosis following the recent commencement of empaglifozin. In 2006, he was diagnosed with Type 2 diabetes. He was overweight (BMI 35 kg/m2) and his mother had Type 2 diabetes. He was started on insulin 6-12 months (plus metformin) after diagnosis due to poor control.

 

In 2011, he had his first episode of DKA (pH 7.16) in the setting of decreased oral intake and omitting insulin for 2 days. In 2013, he had another episode of severe DKA (pH 6.89). Autoantibodies were elevated (islet cell Ab: 12.8 U/ml [<0.8 U/ml]). He cannot recall being informed of the diagnosis of LADA or Type 1 diabetes.

 

In 2016, he presented to a private endocrinologist with poor glycaemic control (HbA1C 10%) and wanting to lose weight. The prior history of DKA was not obtained. He was advised to:

  1. Decrease Novomix 30 from 50 units b.d to 10 units t.d.s.
  2. Restrict carbohydrates.
  3. Start empagliflozin 12.5mg b.d, in addition to metformin 1g b.d

 

Three days after he instituted these changes, he became lethargic and fatigued. On day 6, he developed nausea and vomiting and presented to ED with a glucose of 8 mmol/L, pH 7.14. There was no clinical evidence of sepsis. He was treated for euglycaemic DKA with IV dextrose and insulin. He was discharged on day 4 on subcutaneous insulin.

 

Learning points:

  1. The diagnosis of latent (slow-onset) autoimmune diabetes in the adult is confounded by the increasing incidence of obesity and the rising prevalence of Type 2 diabetes.
  2. Euglycaemic DKA appears to be a class-effect of SGLT-2 inhibitors1,2. They are not currently recommended for use in Type 1 diabetes3,4 .
  1. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium–Glucose Cotransporter 2 Inhibition Diabetes Care 2015;38:1687–1693 | DOI: 10.2337/dc15-0843
  2. Euglycemic Diabetic Ketoacidosis in a Patient With Type 2 Diabetes After Treatment With Empagliflozin Diabetes Care 2016;39:e3 | DOI: 10.2337/dc15-1797
  3. https://www.tga.gov.au/alert/sodium-glucose-co-transporter-2-inhibitors-used-treat-type-2-diabetes
  4. Yehuda Handelsman,et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON THE ASSOCIATION OF SGLT-2 INHIBITORS AND DIABETIC KETOACIDOSIS
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