Euglycemic Diabetic Ketoacidosis Research Articles

Utility of Partitioning of Standard Base Excess in Euglycemic Diabetic Ketoacidosis with Hyperchloremic Acidosis

Utility of Partitioning of Standard Base Excess in Euglycemic Diabetic Ketoacidosis with Hyperchloremic Acidosis

Diabetic acidosis with severe fetal hypoxia in pregnancy: Narrative review and case study.

Diabetic ketoacidosis (DKA) in pregnancy could be a disastrous event with increased maternal and perinatal morbidity and mortality. DKA can occur with a normal blood glucose level, known as euglycemic DKA. It particularly affects pregnant women with type I diabetes. Here, we report the case of a 28 year-old primigravid patient, with a diagnosis of type 1 diabetes for 8 years. This patient consulted our department at 29 weeks of gestation with a previous history of headaches, vomiting and diarrhea for 9 h. Blood glucose level was 8.8 mmol/L with a ketone test positive (>15 mg/dL). Blood test showed high anion gap (17.9 mmol/L) with low serum bicarbonate rate (21 mmol/L). Systemic examination and fetal heart rate (FHR) was reassuring. The patient was subsequently discharged. She returned to the clinic 19 h later with further symptoms of nausea, polyuria-polydipsia, asthenia and a weight loss of 4 kg since the day before. Blood sugar was 14.3 mmol/L and a ketone test was strongly positive. Cardiotocography showed fetal tachycardia and repeated late decelerations. A diagnosis of DKA was made and emergency cesarean was performed for fetal distress. At delivery, pH was acidosis (pH: 7.02, lactates: 6.2). The patient was successfully treated with intravenous hydration and insulin. Neonatal evolution was favorable. Pregnant women with type I diabetes can develop euglycemic DKA. Early recognition and prompt treatment could help prevent severe maternal and fetal adverse outcomes. DKA in pregnant women can induce fetal acidosis with abnormal FHR. In this situation, a cesarean can be performed to improve neonatal outcome even inducing a premature delivery. Prolonged pregnancy can lead to irreversible neonatal brain abnormalities.

The significance of precise diabetes diagnosis: a case of euglycemic diabetic ketoacidosis induced by the introduction of empagliflozin with simultaneous reduction of insulin dosage

Euglycemic diabetic ketoacidosis (euDKA) is a rare but severe metabolic complication of diabetes mellitus characterised by elevated anion gap metabolic acidosis despite normal or mildly elevated blood glucose levels. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as effective antidiabetic medications, yet their use is associated with an increased risk of euDKA, especially when coupled with insulin dose reduction. We present the case of a 50-year-old male with a 20-year history of diabetes mellitus, initially managed with insulin and metformin, who developed euDKA following the introduction of empagliflozin and sitagliptin alongside a reduction in insulin therapy. Despite normoglycaemia the patient exhibited symptoms of ketoacidosis, including chronic fatigue, polydipsia, and polyuria. Diagnostic workup revealed metabolic acidosis, elevated inflammatory markers, acute kidney injury and ketonuria. Subsequent specialised laboratory tests confirmed type 1 diabetes mellitus (T1DM) with the presence of anti-glutamic acid decarboxylase (anti-GAD) antibodies and the absence of C-peptide secretion. Management involved fluid therapy, intravenous insulin and glucose administration. This case underscores the diagnostic challenges of euDKA and emphasises the importance of differentiating between T1DM and T2DM, as management strategies vary significantly. Patient education on insulin therapy and injection techniques is crucial to prevent complications such as improper insulin delivery and dose reduction, which can precipitate euDKA. In conclusion, clinicians should be vigilant for euDKA in patients on SGLT2 inhibitors, particularly when insulin dose reduction is involved. Comprehensive patient education and accurate differentiation between diabetes types are essential for timely diagnosis and optimal management, thereby reducing the risk of severe complications.

Euglycemic Diabetic Ketoacidosis With Acute Renal Failure: A Challenging Case for Clinicians

Euglycemic Diabetic Ketoacidosis With Acute Renal Failure: A Challenging Case for Clinicians

Missed postoperative metabolic acidosis associated with sodium-glucose transporter 2 inhibitors in cardiac surgery patients: a retrospective analysis

The increasing use of sodium glucose transporter 2 inhibitors (SGLT2i) for treating cardiovascular (CV) diseases and type 2 diabetes (T2D) is accompanied by a rise in euglycemic diabetic ketoacidosis occurrences in cardiac surgery patients. Patients undergoing cardiac surgery, due to their pre-existing CV disease which often requires SGLT2i prescriptions, face an increased risk of postoperative metabolic acidosis (MA) or ketoacidosis (KA) associated with SGLT2i, compounded by fasting and surgical stress. The primary aim of this study is to quantify the incidence of SGLT2i-related postoperative MA or KA and to identify related risk factors. We analyzed data retrospectively of 823 cardiac surgery patients, including 46 treated with SGLT2i from November 2019 to October 2022. Among 46 final cohorts treated preoperatively with SGLT2i, 29 (63%) developed postoperative metabolic complications. Of these 46 patients, stratified into two categories based on postoperative laboratory findings, risk factor analysis were conducted and compared. Analysis indicated a prescription duration over one week significantly elevated the risk of complications (Unadjusted OR, 11.7; p = 0.032*; Adjusted OR, 31.58; p = 0.014*). A subgroup analysis showed that a cardiopulmonary bypass duration of 60 min or less significantly raises the risk of SGLT2i-related postoperative MA in patients with a sufficient prescription duration. We omitted the term "diabetes" in describing complications related to SGLT2i, as these issues are not exclusive to T2D patients. Awareness of SGLT2i-related postoperative MA or KA can help clinicians distinguish between non-life-threatening conditions and severe causes, thereby preventing unnecessary tests and ensuring best practice.

Harnessing the Synergy of SGLT2 Inhibitors and Continuous Ketone Monitoring (CKM) in Managing Heart Failure among Patients with Type 1 Diabetes.

Heart failure (HF) management in type 1 diabetes (T1D) is particularly challenging due to its increased prevalence and the associated risks of hospitalization and mortality, driven by diabetic cardiomyopathy. Sodium-glucose cotransporter-2 inhibitors (SGLT2-is) offer a promising avenue for treating HF, specifically the preserved ejection fraction variant most common in T1D, but their utility is hampered by the risk of euglycemic diabetic ketoacidosis (DKA). This review investigates the potential of SGLT2-is in T1D HF management alongside emergent Continuous Ketone Monitoring (CKM) technology as a means to mitigate DKA risk through a comprehensive analysis of clinical trials, observational studies, and reviews. The evidence suggests that SGLT2-is significantly reduce HF hospitalization and enhance cardiovascular outcomes. However, their application in T1D patients remains limited due to DKA concerns. CKM technology emerges as a crucial tool in this context, offering real-time monitoring of ketone levels, which enables the safe incorporation of SGLT2-is into treatment regimes by allowing for early detection and intervention in the development of ketosis. The synergy between SGLT2-is and CKM has the potential to revolutionize HF treatment in T1D, promising improved patient safety, quality of life, and reduced HF-related morbidity and mortality. Future research should aim to employ clinical trials directly assessing this integrated approach, potentially guiding new management protocols for HF in T1D.

An Overview on Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors Induced Euglycemic Diabetic Ketoacidosis: Clinical Manifestation, Mechanism, Diagnosis, Prevention and Treatment

Euglycemic diabetic ketoacidosis is a transient and dangerous metabolic condition characterized by ketoacidosis and considerably lower blood glucose levels which is associated with the usage of newer class of oral antidiabetic medication known as Sodium-glucose cotransporter 2 (SGLT-2) inhibitors. The primary mechanism involved in SGLT2 inhibitors induced eDKA would due to increased lipolysis and ketone body reabsorption. SGLT2i also tend to increase the pancreatic alpha cells, which simultaneously blocks the beta cells, thereby causing an disruption in glucagon/insulin ratio that accounts to enhanced lipolysis and ketogenesis, which is clinically manifested with Fatigueness, stomach pain, nausea and vomiting resulting in reduced blood pressure and dehydration, altered psychological condition, dyspnea, rapid breathing, loss of appetite, pyrexia and tachycardia. Despite lower blood glucose levels or the absence of urine ketones, euglycemic DKA is difficult to diagnose and should be examined in the differential diagnosis of an ill patient who as a previous history of diabetes mellitus. eDKA is often triggered by insulin absence or dose drop, severe acute sickness, dehydration, strenuous activity, surgeries, low-carbohydrate meals, or heavy alcohol or drug abuse. Making the definitive diagnosis using conventional diagnostic tools and clinical standards, as well as coordinating fluid resuscitation, insulin treatment, and electrolyte replacement based on information gained from prompt patient observing and knowledge of resolution criteria, are all components of management and the prevention method includes patient and physician education on risk and precipitating factors and suspending SGLT2 inhibitors therapy may reduce SGLT2 inhibitor-induced eDKA, which are more critical. This review briefly illustrates on the signs & symptoms, mechanism of induction, investigation and diagnosis, prevention and treatment of SGLT2 inhibitors-induced Euglycemic diabetic ketoacidosis (eDKA)

A Case of Type 2 Diabetes with Ipragliflozin Administration Developing Euglycemic Diabetic Ketoacidosis Due to Reduced Food Intake Following Colonoscopy

A Case of Type 2 Diabetes with Ipragliflozin Administration Developing Euglycemic Diabetic Ketoacidosis Due to Reduced Food Intake Following Colonoscopy

The emerging risks of ketoacidosis and its detection by an innovative Breath Ketone Analyser - KetoMetrics

Ketoacidosis is a dangerous condition, of which diabetic ketoacidosis and euglycemic diabetic ketoacidosis are increasingly common in the community due to uncontrol diabetes and its medical management. This paper describes the common situations leading to ketoacidosis and the dilemma facing clinicians in handling this life-threatening condition. The development of an innovative Breath Ketone Analyser has improved the point of care in diabetes management by detecting and preventing the development of dangerous ketoacidosis.

Can euglycemic Diabetic Ketoacidosis Caused by SGLT2 Inhibitors be avoided in Covid-19 and other acute Infections?

We present a case of anion gap euglycemic diabetic ketoacidosis (EuDKA) in a patient with COVID-19 infection. Patients with diabetes mellitus are at increased risk of severe illness, and hyperglycaemia is associated with higher morbidity and mortality in patients infected with COVID-19. A 76-year-old male with diabetes mellitus treated with SGLT2 inhibitor tested positive for COVID-19 infection on day 3 after his admission. In the emergency room he had a high anion gap metabolic acidosis and a blood glucose of 248 mg/dl. His urine tested strongly positive for ketones. A diagnosis of euglycemic diabetic ketoacidosis was made and he was treated with intravenous insulin and normal saline; his antidiabetic medications were stopped. His metabolic acidosis gradually resolved, and he was discharged. Euglycemic diabetic ketoacidosis is a rare complication of COVID-19 infection. It is defined by the American Diabetes Association as the triad of anion gap metabolic acidosis with arterial pH <7.3, serum bicarbonate <18 mmol/l and ketonuria or ketonemia. It is a life-threatening complication which usually occurs in type 1 diabetes mellitus patients but may also occur in type 2 diabetes mellitus patients. As described earlier, it is associated with hyperglycaemia but if blood glucose is low or near normal but <250 mg/dl it is then named euglycemic diabetic ketoacidosis. Patients treated with SGLT2 inhibitors are at increased risk of euglycemic diabetic ketoacidosis. COVID-19 infection precipitated euglycemic diabetic ketoacidosis in our patient. SGLT2 inhibitors must be stopped when this adverse reaction occurs. As their use increases, the risk of this adverse reaction is higher as well. Their prescription should be restricted to trained physicians who are able to educate their patients and treat them appropriately in situations that may arise. COVID-19 infected patients are at increased risk of developing diabetic ketoacidosis or euglycemic ketoacidosis when treated with SGLT-2 inhibitors.It is practical to discontinue the drug at the onset of any symptoms consistent with acute infection to prevent the development of euglycemic diabetic ketoacidosis.

Re-emergence of a forgotten diabetes complication: Euglycemic diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is the most common emergency complication of diabetes. Euglycemic DKA (EDKA), on the other hand, has been known for many years but is a rare and under-recognized condition and constitutes a very small proportion of DKA cases. However, in recent years, an increase in the incidence of EDKA has been observed with the widespread use of sodium-glucose co-transporter 2 inhibitors, which have proven benefits in the treatment of diabetes mellitus and its cardiorenal complications, heart failure, and chronic kidney disease. Unlike classical DKA, these patients without significant hyperglycemia can easily be missed in emergency departments. EDKA should be kept in mind in patients with diabetes presenting with DKA but with a blood glucose level <250 mg/dL. The diagnostic and therapeutic approach after clinical suspicion in these patients is similar to classical DKA and is briefly summarized in this review. The most important point in treatment is that these patients are normoglycemic but have a significant insulin deficiency (relative or absolute). Therefore, insulin is the mainstay of the treatment and should be given together with dextrose solutions to avoid hypoglycemia.

A bumpy ride-Acute recurrent pancreatitis in pregnancy in a Type 2 diabetic, presenting with euglycemic diabetic ketoacidosis: A case report.

A bumpy ride-Acute recurrent pancreatitis in pregnancy in a Type 2 diabetic, presenting with euglycemic diabetic ketoacidosis: A case report.

Sodium-Glucose Cotransporter-2 Inhibitors in Odontogenic Infections

On top of improving glycemic control, sodium-glucose cotransporter-2 inhibitors have been shown to reduce cardiovascular mortality &amp; heart failure hospitalization. Sodium-glucose cotransporter-2 inhibitors have also been gaining momentum as effective reno-protective agents. Recent evidences have shown that sodium-glucose cotransporter-2 inhibitors are transforming the management of heart failure and chronic kidney disease in patients without type 2 diabetes mellitus. In view of the cardioprotective and reno-protective outcomes, as well as the potential benefits that outweigh adverse effects, it is no doubt that there will be continued increased use of sodium-glucose cotransporter-2 inhibitors. However, with use of sodium-glucose cotransporter-2 inhibitors comes risk of adverse effects, in particular diabetic ketoacidosis. Although uncommon, diabetic ketoacidosis is a potentially life-threatening acute metabolic complication. Diabetic ketoacidosis developing during sodium-glucose cotransporter-2 inhibitors use can present with normal blood glucose concentrations (euglycemia). This atypical presentation can delay diagnosis and hence, treatment. It is therefore crucial for dental practitioners to be cognizant of the increased risk of euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitors use, especially during periods of reduced oral intake, such as in patients with odontogenic infection. Euglycemic diabetic ketoacidosis is a diagnosis of exclusion and should be considered as a differential in an ill patient on sodium-glucose cotransporter-2 inhibitors, despite normal blood glucose or absent urine ketones. We report a case of starvation ketosis in a patient with well-controlled type 2 diabetes mellitus, after excisional biopsy of right cervical lymph node and extractions of two lower right molars. Although the patient did not develop euglycemic diabetic ketoacidosis peri-operatively, it was an important diagnosis to exclude considering his high-risk profile of developing euglycemic diabetic ketoacidosis and the potential sequelae of missing the diagnosis.

Identifying Barriers and Facilitators for Increasing Uptake of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors in British Columbia, Canada, using the Consolidated Framework for Implementation Research.

Care gaps remain in modern health care despite the availability of robust, evidence-based medications. Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated profound benefits in improving both cardiovascular and kidney outcomes in patients, the uptake of these medications remain suboptimal, and the causes have not been systematically explored. The purpose of this study was to use the Consolidated Framework for Implementation Research (CFIR) to describe the barriers and facilitators faced by clinicians in British Columbia, Canada, when prescribing an SGLT2 inhibitor. To achieve this, we conducted semistructured interviews using the CFIR with practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Semistructured interviews. British Columbia, Canada. Actively practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia. Twenty-one clinicians were interviewed using questions derived from the CFIR. The audio recordings were transcribed verbatim, and each transcription was individually analyzed in duplicate using thematic analysis. The analysis focused on identifying barriers and facilitators to using SGLT2 inhibitors in clinical practice and coded using the CFIR constructs. Once the transcriptions were coded, overarching themes were created. Five overarching themes were identified to the barriers and facilitators to using SGLT2 inhibitors: current perceptions and beliefs, clinician factors, patient factors, medication factors, and health care system factors. The current perceptions and beliefs were that SGLT2 inhibitors are efficacious and have distinct advantages over other agents but are underutilized in British Columbia. Clinician factors included varying levels of knowledge of and comfort in prescribing SGLT2 inhibitors, and patient factors included intolerable adverse events and additional pill burden, but many were enthusiastic about potential benefits. Multiple SGLT2 inhibitor related adverse events like mycotic infections and euglycemic diabetic ketoacidosis and the difficulty in obtaining reimbursement for these medications were also identified as a barrier to prescribing these medications. Facilitators for the use of SGLT2 inhibitors included consensus among colleagues, influential leaders, and peers in support of their use, and endorsement by national guidelines. The experience from the clinicians regarding costs and the reimbursement process is limited to British Columbia as each province has its own procedures. There may be responder bias as clinicians were approached through purposive sampling. This study highlights different themes to the barriers and facilitators of using SGLT2 inhibitors in British Columbia. The identification of these barriers provides a specific target for improvement, and the facilitators can be leveraged for the increased use of SGLT2 inhibitors. Efforts to address and optimize these barriers and facilitators in a systematic approach may lead to an increase in the use of these efficacious medications.

Impact of COVID-19 Lockdown on Occurrence of Acute Complications of Type 1 and Type 2 Diabetes and Overall Glycemic Management

ObjectivesThe association of diabetes, and COVID-19 infection has been studied extensively; however, the occurrence of diabetic ketoacidosis (DKA) or hyperglycemic/hyperosmolar states (HHS) in adults during the lockdown has not been well characterized. In this study, we aimed to identify the impact of the lockdown on occurrence and severity of DKA/HHS admissions and glycemic management. MethodsA retrospective chart review was conducted of patients admitted to Hamilton Health Sciences with a diagnosis of DKA or HHS from April to September 2019 (pre-lockdown) and from April to September 2020 (lockdown). Adult (≥18 years old) nonpregnant patients with a single admission in the study period were included for study. ResultsThere were 229 admissions related to diabetes, with 171 admissions meeting the inclusion criteria (n=92 pre-lockdown, n=79 lockdown). In the lockdown group, 51.8% of the patients had type 2 diabetes mellitus, with 96.2% of admissions secondary to DKA. When comparing the 2 periods, the lockdown group trended toward higher rates of death (5.4% vs 10.1%, p=0.247) and euglycemic DKA (17.6% vs 24.4%, p=0.403). There were more new diagnoses of type 1 diabetes mellitus in the lockdown group compared with the pre-lockdown group (7.3% vs 16.7%, p=0.230). The average glycated hemoglobin was lower in the lockdown group compared with the pre-lockdown group (11.8% vs 10.4%, p=0.032). ConclusionsOverall, this study is among the first in Canada to assess the impact of the COVID-19 lockdown on admissions due to DKA and HHS. Although no significant differences were noted in severity of admissions, there was a trend toward more new diagnoses of type 1 diabetes mellitus presenting in DKA during the lockdown period.

A 33-Year-Old Man Presented with Abdominal Pain and Vomiting Starting a Day Ago

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are expanding their role beyond the glucose-lowering effects to include reducing body weight and managing the risk of cardiovascular and renal diseases. Accordingly, the number of people with type 2 diabetes using these medications is rapidly increasing. To minimize the potential side effects and ensure safer use, it’s essential to time prescriptions correctly and educate patients thoroughly. Special caution is required when prescribing to patients with symptomatic and severe hyperglycemia who require insulin. Patients should be instructed to discontinue the medication immediately if they experience symptoms like abdominal pain, nausea, or vomiting. Moreover, if a patient taking SGLT-2 inhibitors is in poor general condition, diagnostic tests for euglycemic diabetic ketoacidosis should be performed, even if the blood glucose levels are not elevated. In such cases, prompt fluid resuscitation and intravenous insulin treatment should be initiated. Additionally, the risk of diabetic ketoacidosis may increase under acute stress conditions such as severe infections, trauma, or major surgery. Therefore, it may be necessary to discontinue SGLT-2 inhibitors and switch to other medications for blood glucose management in these situations.

Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis.

Euglycemic diabetic ketoacidosis (DKA) (glucose <250milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561mg/dL, P < 0.001) and potassium (4.3 vs 5.3mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3mmol/L) was 27.3 vs 19.1% (P = 0.23). Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.

Euglycemic Diabetic Ketoacidosis in a Type II Diabetic Patient Treated with Empagliflozin

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are a new class of oral drugs used to treat type 2 diabetes (T2DM). EuGlycemic Diabetic Ketoacidosis (EuDKA) is associated with an almost normal level of blood glucose, causing a delay in its diagnosis and treatment. The diagnosis of EuDKA is a challenge for doctors due to its unusual manifestations. EuDKA is one of the rare complications associated with the use of SGLT-2 inhibitors, but it is serious and dangerous. Early diagnosis and treatment of EuDKA require the knowledge and precision of doctors so that they can quickly and safely restore the acid-base balance. EuDKA appears with a slight increase in blood glucose (less than the level defined in the diagnostic criteria for DKA), metabolic acidosis, and increase in the anion gap. Its manifestations are somewhat different from typical DKA. Patients with type 1 or 2 diabetes who present weakness, nausea and vomiting, and metabolic acidosis and are taking SGLT-2 inhibitors should be evaluated for the presence of urine and/or serum ketones. In this report, we reported a case of euglycemic DKA following the use of SGLT2 inhibitor and its treatment.

Perioperative Management of Patients Receiving Sodium-Glucose Cotransporter 2 Inhibitors: Development of a Clinical Guideline at a Large Academic Medical Center

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology,and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.

THU382 It’s Not What It Seems - Metformin Induced Severe Lactic Acidosis Mimicking Euglycemic Diabetic Ketoacidosis

Abstract Disclosure: M. Shaukat: None. R. Memon: None. M. Mack: None. E. Galarza: None. R. Saeed: None. Diabetic Ketoacidosis (DKA) is a life-threatening complication and, occasionally, the initial presentation of Diabetes Mellitus (DM). DKA can rarely present without elevated blood glucose levels, known as Euglycemic DKA, now typically associated with SGLT-2 inhibitors. Metformin is known to cause lactic acidosis but has not been reliably associated with euglycemic DKA. We present a case of metformin-associated lactic acidosis with renal failure and ketosis mimicking euglycemic DKA. Case: 82-year-old female with a history of DM type 2 on metformin and hypertension presented to the Emergency Department (ED) with complaints of presyncope, vomiting and generalized weakness for two weeks. In the ED, her temp. was 90.3 F and BP was 66/28 mmHg. Her labs revealed a potassium of 5.4mmol/L, bicarbonate 5 mmol/L, Creatinine 3.68 mg/dL (baseline 0.7mg/dL), Anion gap (AG) 45mmol/L, Lactate 25.1 mmol/L and Beta-hydroxybutyrate of 21.4 mg/dL. CT Scan of the chest and abdomen showed a 2 cm liver mass and pancreatitis. She was taken to the ICU and started on antibiotics, IV fluids, and vasopressors. The following day, her lactate was 13.5mg/dL, AG was 37mmol/L and Beta-hydroxybutyrate increased to 53.5mg/dL. Her blood sugars remained between 140-180mg/dL and her hemoglobin A1c was in the prediabetic range at 6.1%. She was thought to be in metformin induced euglycemic diabetic ketoacidosis and was started on an insulin drip with 5% Dextrose and 0.45% Normal Saline. Nephrology was consulted and she underwent hemodialysis for metformin toxicity. She remained on the insulin drip for 48 hours after which she was successfully weaned off. She currently remains off on any antidiabetic medication and is doing well. Discussion: DKA is a life-threatening complication of DM that presents as hyperglycemia, ketonemia, and AGMA. Euglycemic DKA is distinguished by blood glucose levels less than 250mg/dL and is usually seen with pregnancy, fasting states and use of SGLT-2 inhibitors. Previous cases of metformin-associated lactic acidosis (MALA) and concurrent euglycemic DKA have been reported, out of which several patients were concurrently on SGLT-2 inhibitors. After a thorough literature review, we were unable to determine a causal mechanism linking metformin and euglycemic DKA. In the reported cases, we believe that renal failure from various causes precipitated MALA due to decrease metformin clearance, with ketosis caused by starvation and exacerbated by metformin-induced inhibition of hepatic gluconeogenesis, further aggravated by an increase in stress hormones resulting in increased insulin resistance and ultimately leading to the development of the severe ketoacidosis. Even though this phenomenon has previously been referred to as “Metformin-induced euglycemic DKA”, we believe that this is more akin to a mimic, rather than true DKA. Presentation: Thursday, June 15, 2023