Published April 1, 2020 | Version v1
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Diabetic Ketoacidosis, Lactic Acidosis and Alcoholic Acidosis in a Type 2 Diabetic Male: Synergic Effects of SGLT-2 Inhibitors with Heavy Alcohol Consumption

Authors/Creators

  • 1. Department of Endocrinology Hospital CIMA, San José, Costa Rica and School of Medicine, Universidad de Ciencias Médicas San José, Costa Rica
  • 2. Emergency Department Hospital CIMA, San José, Costa Rica

Description

Abstract

Objective: To report a Type 2 Diabetic (T2DM) heavy drinker patient who developed Euglycemic Diabetic Ketoacidosis (eDKA), Lactic Acidosis (LA) and Alcohol Ketoacidosis (AKA) chronically treated with a sodium-glucose co-transporter 2 SGLT2 inhibitor (SGLT2i) and metformin.

Methods: We describe the clinical presentation and management of a 62-year-old T2DM male with eDKA, LA and AKD while taking empagliflozin and metformin.

Results: The patient presented to the emergency department with nausea, vomiting, myalgia and malaise at the end of a binge of alcohol ingestion. Body mass index was 27.9 kg/m2 and blood pressure 120/80 mmHg. Baseline glucose concentration was 129 mg/dL, sodium 124 mmol/L, potassium 4.2 mmol/L, chloride 94.6 mmol/L, blood urea nitrogen 14.4 mg/dL, creatinine 0.75 mg/dL, pH 7.27, PO2, 104.4 mmHg,PCO2, 20.5mmHG, bicarbonate of 9.4 mmol/L, beta-hydroxybutyrate 7.81 mmol/L and lactate 25.1 mg/dL. The estimated osmolality was 269.5 mOsm/L and the anion gap was 20 mEq/L. The patient received intravenous saline solutions, insulin infusion at 0.5 U/hour for 12 hours and had an oral feeding. During hospitalization glucose levels were kept between 90-156 mg/dL, metabolic acidosis and electrolyte abnormalities reverted within four hours. The patient was discharged with a DPP-4 inhibitor and metformin.

Conclusions: This T2DM non-insulin requiring patient chronically treated with SGLT2i developed eDKA, LA and AKA after a binge ofalcohol ingestion. Heavy ethanol intake combined with SGLT-2i induced biochemical alterations leading to a combined metabolic acidosis.

Abbreviations

eDKA: Euglycemic Diabetes Ketoacidosis; LA: Lactic Acidosis; HbA1c: Glycosylated Hemoglobin A1c; SGLT 2i: Sodium-Glucose Co-Transporter Inhibitors

Notes

International Journal of Clinical and Medical Cases (ISSN:2517-7346)

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References

  • Musso G, Gambino R, Cassader M, Pagano G. A novel approach to control hyperglycemia in type 2 diabetes: sodium glucose cotransport (SGLT) inhibitors: systematic review and meta-analysis of randomized trials. Ann Med. 2012 Jun; 44(4):375-393.
  • Vallon V. The mechanisms and therapeutic potential of SGLT-2inhibitors in diabetes mellitus. Annu Rev Med. 2015;66:255-270.
  • Liu XY, Zhang N, Chen R, Zhao JG, Yu P. Efficacy and safety of sodium glucose cotransporter 2 inhibitors in type 2 diabetes: ameta-analysis of randomized controlled trials for 1 to 2 years. JDiabetes Complications. 2015 Nov-Dec;29(8):1295-1303.
  • Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, et al.Empagliflozin, cardiovascular outcomes, and mortality in type 2diabetes. N Engl J Med. 2015 Nov;373(22):2117-2128.
  • Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, et al.Canagliflozin and cardiovascular and renal events in type 2diabetes. N Engl J Med. 2017 Aug;377(7):644–657.
  • Wiviott SD, Raz I, Bonaca MP, Mosenzon O, Kato ET, et al.Dapagliflozin and Cardiovascular Out-comes in Type 2 Diabetes.N Engl J Med. 2019 Jan;380(4):347-357.
  • Perkovick V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, etal. Canagliflozin and Renal Out-comes in Type 2 Diabetes with Nephropathy. N Engl J Med.2019; 380;2295-2306.
  • Handelsman Y, Henry RR, Bloomgarden ZT, Dagogo-JackS, De Fronzo RA, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on the association of SGLT-2 inhibitors and diabetic ketoacidosis. Endocr Pract. 2016 Jun;22(6):753-762.
  • Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, et al. Euglycemicdiabetic ketoacidosis: a potential complication of treatment withsodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015Sep;38(9):1687-1693.
  • Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern withSGLT2 inhibitors. Diabetes Care. 2015 Sep;38(9):1638-1642.
  • Burke KR, Schumacher CA, Harpe SE. SGLT2 Inhibitors: A Systematic Review of Diabetic Ketoacidosis and Related Risk Factors in the Primary Literature. Pharmacotherapy. 2017Feb;37(2):187-194.
  • Jiménez-Montero JG, Mora-Aguilar CJ,ChihHao, Chen-Ku. Diabetic Ketoacidosis in a patient with type 1 diabetes mellitus treated with low insulin in combination with empagliflozin. ACE Clinical Case Rep. 2018;4:6.
  • Jiménez-Montero JG. Diabetic Ketoacidosis Linked with Sodium Glucose Co-Transporter 2 Inhibitors in an Elderly Patient with Type 2 Diabetes. Int J EndocrinolMetabDisord.2019 Apr;5:1.
  • Qiu H, Novikov A, Vallon V. Ketosis and diabetic ketoacidosis in response to SGLT-2 inhibitors: Basic mechanisms and therapeutic persepectives. Diabetes Metab Res Rev. 2017 Jul;33(5):1-9.
  • Bonner C, Kerr-Conte J, Gmyr V, Queniat G, Moerman E, et al.Inhibition of the glucose transporter SGLT2 with dapagliflozin in pancreatic alpha cells triggers glucagon secretion. Nat Med. 2015May;21(5):512-517.
  • Wrenn KD, Slovis CM, Minion GE, Rutkowski R. The syndrome of alcoholic ketoacidosis. Am J Med. 1991 Aug;91(2):119-128.
  • McGuire LC, Cruickshank AM, Munro PT. Alcoholic ketoacidosis. Emerg Med J. 2006 Jun;23(6):417-420.
  • Fulop M, Bock J, Ben-Ezra J, Antony M, Danzig J, et al. Plasma lactate and 3-hydroxybutyrate levels in patients with acute ethanol intoxication. Am J Med. 1986 Feb;80(2):191-194.
  • Schwetz V, Eisner F, Schilcher G, Eller K, Plank J, et al. Combined metformin-associated lactic acidosis and euglycemic ketoacidosis. Wien Klin Wochenschr. 2017 Sep;129(17-18):646–649.
  • Halperin ML, Hammeke M, Josse RG, Jungas RL. Metabolic acidosis in the alcoholic: a pathophysiologic approach. Metabolism. 1983Mar;32(3):308-315.
  • Palmer JP. Alcoholic ketoacidosis: clinical and laboratory presentation, pathophysiology and treatment. ClinEndocrinMetab.1983 Jul;12(2):381-389.
  • Levy LJ, Duga J, Girgis M, Gordon EE. Ketoacidosis associated with alcoholism in non-diabetic subjects. Ann Intern Med. 1973Feb;78(2):213-219.
  • Umpierrez GE, DiGirolamo M, Tuvlin JA, Isaacs SD, Bhoola SM, etal. Differences in metabolic and hormonal milieu in diabetic and alcohol-induced ketoacidosis. J Crit Care. 2000 Jun;15(2):52-59.