Laboratory outcomes showed severe postoperative raised anion difference metabolic acidosis with regular blood sugar and elevated bloodstream ketone levels. who was simply known for coronary artery bypass graft medical procedures. Outcomes A 60-year-old guy with type 2 diabetes mellitus created euglycemic DKA a couple of hours after coronary artery bypass graft medical procedures. Laboratory results demonstrated acute postoperative raised anion difference metabolic acidosis with regular blood sugar and elevated bloodstream ketone levels. It had been later uncovered that the individual was treated as an outpatient with empagliflozin; the final dosage was used 48 hours ahead of his process. Conclusion Euglycemic DKA can occur postoperatively in patients with a history of SGLT2 inhibitor use, even 48 hours after the discontinuation of therapy. This case highlights the need to revisit the recommended time to discontinue these brokers, specifically prior to major medical procedures, because their pharmacokinetic effects may persist after 24 hours of discontinuation, putting patients at risk for postoperative euglycemic DKA. strong class=”kwd-title” Key words: euglycemic diabetic ketoacidosis, SGLT2 inhibitors, type 2 diabetes mellitus strong class=”kwd-title” Abbreviations: CABG, coronary artery bypass graft; DKA, diabetic ketoacidosis; DM, diabetes mellitus; SGLT2, sodium-glucose cotransporter 2 inhibitor Introduction By 2014, and within 2 years, 3 sodium-glucose cotransporter 2 (SGLT2) inhibitors, namely canagliflozin, dapagliflozin, and empagliflozin, were approved by the U.S. Food and Drug Administration as a novel class of medications for the treatment of diabetes mellitus (DM). SGLT2 inhibitors lower serum glucose levels by blocking glucose reabsorption in the kidneys through a mechanism impartial of insulin.1,2 Multiple studies have revealed that this class of medications reduces the risk of hypoglycemia, promotes weight loss, reduces cardiovascular risk, and slows the progression of albuminuria, which has resulted in a significant increase in their use over the past few years.3,4 In the U.S., SGLT2 inhibitors are only approved for the treatment of type 2 DM due to safety issues in type 1 DM. However, off-label use in type 1 DM is usually common.5 SGLT2 inhibitors have been associated with an increased risk of diabetic ketoacidosis (DKA), which is characteristically associated with paradoxical normal or slightly elevated serum glucose levels, referred to as euglycemic DKA. Between March 2013 and June 2014, 20 cases of SGLT2-related euglycemic DKA were reported, causing the U.S. Food and Drug Administration to issue a security warning.5,6 Some explained precipitating factors for SGLT2 inhibitor-related euglycemic DKA include acute illness, surgery, a low-calorie intake, and excessive alcohol use.1,3,4 Therefore, the American Association of Clinical Endocrinologists and the American College of Endocrinology advise that patients who are to undergo surgery should quit taking their SGLT2 inhibitors at least 24 hours before surgery to reduce the risk of euglycemic DKA in the postoperative period.5 We report a case of euglycemic DKA occurring postoperatively in a patient who halted SGLT2 inhibitor therapy 48 hours before surgery. Case Statement A 60-year-old man was referred to our hospital for coronary artery bypass graft (CABG) surgery following JNJ-31020028 cardiac catheterization at the referring hospital, which revealed triple-vessel disease. His medical history was significant for coronary artery disease, hypercholesterolemia, JNJ-31020028 and type 2 DM diagnosed 15 years previously. He was taking glimepiride (2 mg twice daily), metformin (1000 mg twice daily), subcutaneous semaglutide (0.25 mg weekly), and empagliflozin (10 mg orally daily). The latter 2 medications were started around a 12 months prior to presentation at our hospital but were not on the medication list that he provided on admission. On introduction at our hospital, he was asymptomatic, and vital signs were within normal limits. Laboratory testing revealed a Rabbit Polyclonal to PLCB3 (phospho-Ser1105) white blood cell count of 7.6 K/L (reference range: 4.8-10.8 K/L), hemoglobin of 14.6 g/dL (14-18 g/dL), serum glucose of 157 mg/dL (59-140 mg/dL), bicarbonate of 24 mmol/L (23-32 mmol/L), anion space of 12 mmol/L (3-11 mmol/L), troponin of 0.09 ng/mL (0.00-0.02 ng/mL), and glycated hemoglobin of 9.6% (81 mmol/mol). Urinalysis revealed glucosuria JNJ-31020028 of 1000 mg/dL and ketonuria of 15 mg/dL. His oral antihyperglycemic medications were withheld, and he was placed on a subcutaneous insulin regimen for inpatient glucose control. On the third day (around 42 hours) of admission, the patient underwent CABG surgery. Within just a few hours following medical procedures, the patient developed elevated anion space metabolic acidosis with an arterial pH of 7.275, a reduced bicarbonate level of 15 mmol/L, and an increased anion gap of 25 mmol/L..He was taking glimepiride (2 mg twice daily), metformin (1000 mg twice daily), subcutaneous semaglutide (0.25 mg weekly), and empagliflozin (10 mg orally daily). of therapy. This case highlights the need to revisit the recommended time to discontinue these brokers, specifically prior to major medical procedures, because their pharmacokinetic effects may persist after 24 hours of discontinuation, putting patients at risk for postoperative euglycemic DKA. strong class=”kwd-title” Key words: euglycemic diabetic ketoacidosis, SGLT2 inhibitors, type 2 diabetes mellitus strong class=”kwd-title” Abbreviations: CABG, coronary artery bypass graft; DKA, diabetic ketoacidosis; DM, diabetes mellitus; SGLT2, sodium-glucose cotransporter 2 inhibitor Introduction By 2014, and within 2 years, 3 sodium-glucose cotransporter 2 (SGLT2) inhibitors, namely canagliflozin, dapagliflozin, and empagliflozin, were approved by the U.S. Food and Drug Administration as a novel class of medications for the treatment of diabetes mellitus (DM). SGLT2 inhibitors lower serum glucose levels by blocking glucose reabsorption in the kidneys through a mechanism impartial of insulin.1,2 Multiple studies have revealed that this class of medications reduces the risk of hypoglycemia, promotes weight loss, reduces cardiovascular risk, and slows the progression of albuminuria, which has resulted in a significant increase in their use over the past few years.3,4 In the U.S., SGLT2 inhibitors are only approved for the treatment of type 2 DM due to safety issues in type 1 DM. However, off-label use in type 1 DM is usually common.5 SGLT2 inhibitors have been associated with an increased risk of diabetic ketoacidosis (DKA), which is characteristically associated with paradoxical normal or slightly elevated serum glucose levels, referred to as euglycemic DKA. Between March 2013 and June 2014, 20 cases of SGLT2-related euglycemic DKA were reported, causing the U.S. Food and Drug Administration to issue a safety warning.5,6 Some explained precipitating factors for SGLT2 inhibitor-related euglycemic DKA include acute illness, surgery, a low-calorie intake, and excessive alcohol use.1,3,4 Therefore, the American Association of Clinical Endocrinologists and the American College of Endocrinology advise that patients who are to undergo surgery should quit taking their SGLT2 inhibitors at least 24 hours before surgery to reduce the risk of euglycemic DKA in the postoperative period.5 We report a case of euglycemic DKA occurring postoperatively in a patient who halted SGLT2 inhibitor therapy 48 hours before surgery. Case Statement A 60-year-old man was referred to our hospital for coronary artery bypass graft (CABG) surgery following cardiac catheterization at the referring hospital, which revealed triple-vessel disease. His medical history was significant for coronary artery disease, hypercholesterolemia, and type 2 DM diagnosed 15 years previously. He was taking glimepiride (2 mg twice daily), metformin (1000 mg twice daily), subcutaneous semaglutide (0.25 mg weekly), and empagliflozin (10 mg orally daily). The latter 2 medications were started around a 12 months prior to presentation at our hospital but were not on the medication list that he provided on admission. On introduction at our hospital, he was asymptomatic, and vital signs were within normal limits. Laboratory testing revealed a white blood cell count of 7.6 K/L (reference range: 4.8-10.8 K/L), hemoglobin of 14.6 g/dL (14-18 g/dL), serum glucose of 157 mg/dL (59-140 mg/dL), bicarbonate of 24 mmol/L (23-32 mmol/L), anion space of 12 mmol/L (3-11 mmol/L), troponin of 0.09 ng/mL (0.00-0.02 ng/mL), and glycated hemoglobin of 9.6% (81 mmol/mol). Urinalysis revealed glucosuria of 1000 mg/dL and ketonuria of 15 mg/dL. His oral antihyperglycemic medications were withheld, and he was placed on a subcutaneous insulin regimen for inpatient glucose control. On the third day (around 42 hours) of admission, the patient underwent CABG surgery. Within just a few hours following surgery, the patient developed elevated anion space metabolic acidosis with an arterial pH of 7.275, a reduced bicarbonate level of 15 mmol/L, and an increased anion gap of 25 mmol/L. The serum glucose level was normal, at 138 mg/dL (59-140 mg/dL), but.
