Fellow Sparrow Hospital/MSU Lansing, Michigan, United States
Introduction : Sodium-Glucose Transport Protein 2 (SGLT-2) inhibitors have become a cornerstone treatment for patients with type 2 diabetes mellitus given the heart failure and proteinuria benefit. This class of medications lowers the renal glucose threshold resulting in decreased reabsorption of glucose and increased glucosuria. A complication of SGLT-2 inhibitor use is euglycemic diabetic ketoacidosis (DKA) which results from the decreased renal reabsorption of glucose resulting in serum glucose levels < 150 mg/dL. Here we present a case of a patient who had prolonged glucosuria despite discontinuation of SGLT-2 inhibitor.
Case(s) Description : We have a 60 year old male with type 2 diabetes on insulin and Jardiance. He underwent gastric sleeve procedure complicated with DKA post procedure. We advised stopping Jardiance due to DKA episode however it was not stopped on his paperwork and he continued to take it. 20 days later he was not feeling well and had labs done and was sent to the emergency room for a blood sugar of 127 mg/dL (65-99), anion gap of 28 (2-16), bicarbonate of 12 mmol/L (20-32) and beta hydroxybutyrate of >82 mg/dL (< 4.10). He last took Jardiance on the day of admission. He was treated for euglycemic DKA and transitioned. He then had poor oral intake and his anion gap reopened and acidosis returned. He was placed back on insulin drip and then transitioned again after 2 days. The next day labs showed persistence of normal anion gap with no acidosis however beta hydroxybutyrate was still elevated at 51.7 with urinalysis showing 3+ ketones and 4+ glucose. Protein intake was increased and he was placed on lactated ringers to help clear ketones. Insulin dose was adjusted to suppress glucose to < 150 mg/dL to prevent any further glucosuria. Urinalysis, beta hydroxybutyrate, and glucose was monitored. After 11 days post Jardiance use, his urinalysis showed no glucosuria. On discharge there were still 1+ ketones in urine and beta hydroxybutyrate was 14.4 mg/dL. 3 days post discharge, urinalysis still showed 1+ ketones and beta hydroxybutyrate level was 16.2 mg/dL and this was attributed to his post bariatric surgery diet.
Discussion : Prolonged glucosuria was an interesting phenomenon in this case. The half life of SGLT-2 inhibitors is about 12 hours equating to 3 days for medication effect to wear off. Case reports that have suggested glucosuria can persist for up to 10 days. The exact mechanism is unknown. However, given the potential to occur, these patients are susceptible to recurrence of DKA. This could occur due to inadequate oral intake as well as reduced endogenous insulin secretion from the lower plasma glucose levels. In 2016, AACE and ACE released a joint statement recommending stopping SGLT-2 inhibitors at least 24 hours prior to surgery and continuing to hold until patients can tolerate normal diet. Post bariatric surgery, the timing of the SGLT2 inhibitor resumption is difficult due to dietary restrictions. This case does highlight a potential consequence of SGLT2 discontinuation which is important in the perioperative period as high clinical suspicion is needed to detect euglycemic DKA before serious consequences occur.
