Anion gap acidosis after pancreaticoduodenectomy in patient taking empagliflozin

Abstract

Background: Pancreaticoduodenectomy patients are carefully monitored in the postoperative setting for hyperglycemia and other metabolic abnormalities. The increasing use of SGLT-2 inhibitors, such as empagliflozin, in diabetic patients have led to an increased incidence of euglycemic diabetic ketoacidosis. In this case report, we highlight a 74-year-old postoperative pancreaticoduodenectomy patient taking empagliflozin preoperatively with an unexplained anion gap acidosis on postoperative day 1. He was found to have a serum CO2 of 11 mmol/L and anion gap of 24 mmol/L with a glucose of 144 mg/dL. Further workup demonstrated glucosuria, ketonuria and an elevated serum beta hydroxybutyrate. In combination with the physiologic stress of a pancreaticoduodenectomy, his anion gap acidosis was attributed to euglycemic diabetic ketoacidosis secondary to his empagliflozin. He was treated with IV fluid resuscitation, IV insulin infusion, and electrolyte replacement. His anion gap acidosis had resolved within 24 hours of this therapy, and the patient remained asymptomatic.