Background: Sodium-glucose cotransoporter-2 (SGLT2) inhibitors are the newest class of anti-hyperglycemic drugs available for the treatment of type 2 diabetes. Evidence has emerged regarding their association with diabetic ketoacidosis (DKA).
Aims: The aim of this study was to review cases of SGLT2 inhibitor associated DKA to identify similarities and risk factors which may predict patients at risk DKA with the use of these drugs.
Methods: Thirteen cases within South Australia were identified. A search of the Therapeutic Goods Administration (TGA) of Australia reporting database for cases of SGLT2 inhibitor associated DKA was performed up until April 2017.
Results: Of the 13 patients, 8 had type 2 diabetes and 5 type 1 diabetes although 3 had been incorrectly diagnosed as type 2 and retrospectively identified as having type 1 diabetes after DKA presentation. Nine patients required admission to intensive care. All patients were treated with an IV insulin and dextrose infusion, most requiring 48 hours of therapy. A clear precipitant was identified in 12. Treating doctors initially missed the diagnosis of DKA in 2 cases, and were not aware of the association of SGLT2 inhibitors and DKA in 6.
From April 2017, 85 cases of SGLT2 inhibitor associated DKA had been reported to the TGA, 3 were duplicate reports. Twenty four had type 2 diabetes, 9 had type 1 diabetes, 2 patients were non-diabetic and diabetic status was unreported in 47. A clear precipitant was reported in 22.
Conclusions: SGLT2 inhibitors are associated with DKA in type 2 diabetes, type 1 diabetes and non-diabetics. Precipitants including infection, surgery, reductions in insulin and carbohydrate intake were present in most cases, however episodes also occurred de novo. Guidelines should recommend the temporary cessation of these drugs during acute illness and perioperatively. Diabetic type should be re-examined upon DKA presentation. A lack of awareness, along with an absence of significant hyperglycaemia may delay diagnosis and treatment.