POST SURGICAL BYPASS OF DIABETIC KETOACIDOSIS PROTOCOL

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Serum–glucose cotransporter-2 (SGLT-2) inhibitors are associated with potential euglycemic diabetic ketoacidosis (eDKA) in patients with type 1 and type 2 diabetes mellitus (T2DM). We describe a case of eDKA in a T2DM patient after gastric bypass surgery, treated with empagliflozin monotherapy, which exposed limitations of standardized DKA protocols. CASE PRESENTATION: A 49-year-old male with a history of morbid obesity and T2DM presented with three weeks of lethargy and weakness, in the setting of recent Roux-en-Y gastric bypass surgery. Previously, his T2DM was controlled with dulaglutide, insulin, and metformin. Following his surgery he was switched to empagliflozin only. On admission, the patient had a pH of 7.14, anion gap of 27, betahydroxybutyrate level of 9.98, ketonuria, and a glucose level of 178. In the ICU, he was maintained on IV insulin and D5/NS infusion. He required up to 8ml/hour of IV insulin due to difficulty controlling his ketoacidosis and consequently required high doses of supplemental dextrose, deviating substantially from standard DKA protocol. After 48 hours, his anion gap closed and he was transitioned to a subcutaneous basal-bolus insulin regimen. At discharge, empagliflozin was discontinued and he was prescribed a basal-bolus insulin regimen. DISCUSSION: SGLT-2 inhibitors present an invaluable option in managing diabetes mellitus. While SGLT-2 inhibitors are often used as monotherapy, eDKA can be clinically difficult to differentiate from routine complications of post-gastric bypass surgery. This may delay the diagnosis while increasing the severity of eDKA, health care costs, and length of hospital admission. The proposed mechanism of eDKA and SGLT-2 inhibitors involves increased urinary ketone reabsorption and large amounts of glucose in the urine in the presence of an increased rate of gluconeogenesis and free fatty acid release (1-3). Precipitants include a reduction of co-regimented insulin, alcohol consumption, infection, prolonged exercise, and reduced carbohydrate intake (1). In the post-operative setting, the duration of eDKA in patients with T2DM treated with SGLT-2 inhibitors is poorly defined and often requires several days of intravenous insulin therapy (1). Stopping this medication 24 to 48 hours prior to surgery, due to its half-life of about 12 hours, has not demonstrated significant benefit (1). CONCLUSIONS: SGLT-2 inhibitors present an invaluable option in managing diabetes mellitus. Importance of their risk to cause eDKA has become more relevant to prescribers, considering the increased number of case reports present to date. While SGLT-2 inhibitors are often used as monotherapy, eDKA can be clinically difficult to differentiate from routine complications of post-gastric bypass surgery. This may delay the diagnosis while increasing the severity of eDKA, health care costs, and length of hospital admission. Reference #1: Peters A., Buschur E., Buse J., Cohan P., Diner J., and Hirsch I. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care 2015 Sep; 38(9): 1687-1693 Reference #2: Bashir J., Nalla P., Peter R., Bain S., Chudleigh R. A Case Series of DKA Occuring in Patients Receiving Treatment with SGLT-2 Inbitors. Diabetes Obes Metab. 2018; 20:1800-1801 Reference #3: Ireland JT, Thomson WS. Euglycemic diabetic ketoacidosis. BMJ1973;3:107 DISCLOSURES: No relevant relationships by Rahul Chaudhari, source=Web Response No relevant relationships by Stephen Schwartz, source=Web Response No relevant relationships by cyrus vahdatpour, source=Web Response