Eugylcemic Diabetic Ketoacidosis: An Atypical Presentation of Latent Autoimmune Diabetes in Adults (LADA) with Concurrent SGLT2-Inhibitor Use

Department

Internal Medicine

Document Type

Conference Proceeding

Publication Title

American Journal of Respiratory and Critical Care Medicine

Conference Name

ATS 2020 International Conference

Conference Date

2020-05-01

Abstract

Introduction: Diabetic ketoacidosis (DKA) is a common medical emergency which often requires ICU care due to its extreme metabolic disarrangements. It is defined as an elevated serum glucose level at least >250 mg/dl, elevated serum ketone level with an anion gap metabolic acidosis. We describe an atypical case of ketoacidosis that presented as euglycemic (serum glucose <250 mg/dl) in the setting of SGLT2-inhibitor use in a patient with undiagnosed latent autoimmune diabetes in adults (LADA). Case: A 57-year-old female with a past medical history of presumed type 2 diabetes mellitus presented with a two-day history of generalized malaise and one-day history of nausea and vomiting. She received her diagnosis of type 2 diabetes mellitus two years prior to presentation and was initially exclusively on metformin. Two months prior to presentation, she was switched to dapagliflozin-metformin for better glycemic control. On exam, she appeared lethargic but oriented with Kussmaul respirations and an extremely dry oral mucosa. Bloodwork revealed a glucose level of 249 mg/dl, severe acidosis with a pH of 6.9, anion gap of 26, and a serum beta-hydroxybutyrate of 14.2 mEq/L. She was initiated on an intravenous insulin drip and fluid resuscitated with crystalloids along with dextrose. Her acidosis resolved within 24 hours of therapy. She tested positive for anti-glutamic acid decarboxylase (GAD) autoantibodies which is suggestive of LADA. She was initiated on subcutaneous insulin therapy and her dapagliflozin-metformin was stopped. She was discharged without further complications. Discussion: DKA is a well-known complication in the diabetic population. Euglycemic DKA is a unique presentation of ketoacidosis that is defined as an elevated anion gap metabolic acidosis without significant hyperglycemia. There have been case reports showed the potential associations between SGLT2 inhibitors with euglycemic DKA. The proposed mechanism is that SGLT2 inhibitors induce glucosuria, which results in decreased serum glucose and a subsequent lower plasma insulin level. This may potentially enhance lipolysis and ketogenesis in the liver, leading to an increase of ketone production with near-normal serum glucose level. In patients with LADA who already have a lower circulating plasma insulin level, this will increase the risk of developing ketoacidosis. With the rising utilization of SGLT2 inhibitors, clinicians should be aware of the potential risk of ketoacidosis especially in patients with possible undiagnosed LADA. We emphasize the importance of early identification of LADA prior to initiating such medication as it could predispose patients with adverse outcomes such as ketoacidosis.

DOI

10.1164/ajrccm-conference.2020.201.1_MeetingAbstracts.A5167

Volume

201

Publication Date

5-1-2020

Publisher

American Thoracic Society

Comments

Thematic Poster Session

C44. Critical Care Case Reports: Metabolic, Renal, And Endocrine

Abstract A5167

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