Abstract #1085426: Clinical Characteristics and Outcomes of Ketogenic Diet or Very Low Carbohydrate Diet Induced Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Co-Transporter-2 Inhibitors

Abstract

Euglycemic diabetic ketoacidosis (EDKA) linked to Sodium-Glucose Co-Transporter-2 Inhibitors (SGLT-2i) use in diabetics is increasingly noticed. The underlying mechanism is primarily increased lipolysis and ketone body reabsorption. A ketogenic diet or very low-carbohydrate diet (VLCD) commonly adopted by diabetic patients also enhances body ketosis by breaking down fats into energy sources. However, this diet in SGLT-2i users was observed to trigger EDKA. We aim to understand the patient-specific factors and review the literature of this cohort of patients. Several databases were carefully analyzed to distinguish patient-specific risk factors and clinical characteristics of ketogenic diet-induced EDKA in patients on SGLT-2i. The patient’s symptoms, clinical profile, laboratory results, and safety of dietary changes in SLGT-2i were reviewed. A total of 13 case reports identifying 14 patients on a ketogenic diet and SGLT-2i diagnosed with EDKA were thoroughly reviewed. There were found to be more females (8/14) than males (6/14); median age was 51.02 ± 11.26. Of the 14 patients, 12 (85%) were associated with Type-2 DM, 1 (7%). Duration of treatment with an SGLT2 inhibitor before EKA onset varies from 1 to 365 days. Duration of consuming a ketogenic diet or VLCD before EDKA onset varies from 1 to 90days, with over 90% of patients hospitalized in < 4 weeks after starting the diet. At presentation, average blood glucose was 167.50 ± 41.80, pH 7.10 ± 0.10, HCO3 8.1 ± 3.0 mmol/L, potassium 4.2 ± 1.1, anion-gap 23.6 ± 3.5 mmol/L, and the average HbA1C was 10 ± 2.4. Hospital stay ranged from 1 to 15 days. None of the patients were reinitiated on SGLT-2i, and 2/4 of patients reported were back on the Ketogenic diet or VLCD upon patient questioning. Despite the popularity of the ketogenic diet and VLCD for weight loss, their use in diabetics taking SGLT-2i is associated with EDKA. Physicians should educate their patients with diabetes taking SGLT-2i about the risk of EDKA. In addition, patients should be counseled on the importance of including their physician in any decisions relating to significant changes in diet or exercise routines. Further research is needed to address if SGLT-2i’s are permanently discontinued in patients with diabetes on SGLT-2i’s and the ketogenic diet that developed EDKA.