SGLT2 inhibitors and the risk of diabetic ketoacidosis

Abstract

AbstractThis case report highlights the potentially potent glucose lowering effect of adding an SGLT2 inhibitor to insulin therapy in patients with insulin‐treated diabetes. For our patient this had serious, unintended consequences. We describe a 58‐year‐old lady who had a presumed diagnosis of type 2 diabetes treated with metformin and a twice‐daily biphasic insulin regimen. She was commenced on dapagliflozin by her general practitioner and her blood glucose levels fell significantly over a period of several weeks leading, on occasions, to hypoglycaemia. Consequently, steady insulin dose reductions were made over this period leading eventually to the complete withdrawal of insulin treatment. Within 36 hours of the cessation of insulin treatment the patient was admitted to hospital as an emergency with severe diabetic ketoacidosis (DKA), requiring management on an intensive care unit.This case highlights that DKA can develop in patients with diabetes treated with insulin and SGLT2 inhibitors. Whether type 1 or type 2 diabetes, the SGLT2 inhibitor can reduce insulin requirements significantly. While the glucose may be falling even into normal ranges, the patient is likely becoming insulinopenic leading to muscle and fat metabolism and ketosis. The importance of this being a recognised consequence of SGLT2 inhibitor therapy was recently highlighted in a US Food and Drug Administration alert. Copyright © 2015 John Wiley & Sons.