EC Pharmacology And Toxicology

Purpose: Since the approval of sodium-glucose cotransporter-2 inhibitors (SGLT2i), there has been an increase in reported cases of diabetic ketoacidosis (DKA) in patients with type 2 diabetes. While DKA typically presents as hyperglycemic DKA, many of these patients developed euglycemic DKA (euDKA). The incidence of euDKA remains unknown. Given the diagnostic dilemma posed by normoglycemia or lower than expected serum glucose levels, euDKA has been associated with worse outcomes compared to classic DKA, likely due to delays in diagnosis and treatment. This investigator-initiated study aims to evaluate the incidence of euDKA in patients newly initiated on a SGLT2i while admitted to Loma Linda University Health (LLUH) Medical Center.

Methodology: This retrospective cohort study involved collecting data on patients initiated on an SGLT2i while admitted to the LLUH Medical Center. The primary outcome of this study was to evaluate rates of euDKA following inpatient initiation of SGLT2i. As a subgroup analysis, we examined potential risk factors for euDKA, including infection or sepsis, recent surgery or trauma, or recent procedures. We included adult patients over the age of 18 who were started on an SGLTi, regardless of pre-existing conditions.

Study Design: This retrospective cohort study is descriptive and aims to characterize the incidence of euDKA in admitted patients prescribed an SGLT2i.

Results: A total of 1,604 patients who were admitted to LLUH Medical Center and prescribed an SGLT2i were included from December 2016 - September 2023. Regarding the primary outcome of the incidence of euDKA, we were not able to diagnose a single patient. While most patients had lab values for anion gap, and fewer had lab values for arterial pH, none had labs drawn for ketones, either from urinalysis or serum β-hydroxybutyrate.

Conclusion: Our study indicates that clinicians may be missing diagnosis of euDKA in admitted patients prescribed an SGLT2i. Implementing a hospital-wide protocol for these patients may help prevent euDKA from going unnoticed, potentially leading to earlier intervention and improved outcomes. Further research is warranted to investigate the relationship between the timing of SGLT2i initiation and the incidence of euDKA.

 Keywords: Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i); Diabetic Ketoacidosis (DKA); Euglycemic DKA (euDKA); Loma Linda University Health (LLUH)

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