ODP212 Inpatient Euglycemic DKA due to SGLT2 Inhibitors – Lessons From a Case Series and Strategies to Decrease Incidence
Authors: Burkhardt Daniel , Mehta Paras , Robinson Andrew , Rushakoff Robert 
Published: November 2022

Abstract

Background
In the past decade, sodium-glucose co-transporter 2 inhibitors (SGLT2i) have revolutionized diabetes mellitus (DM) care due to reduction of major cardiovascular events, heart failure hospitalizations, renal disease progression, and all-cause mortality. SGLT2i are now recommended by the ADA as a second-line agent for many patients with DM. A rare but concerning side effect of SGLT2i is euglycemic DKA (eDKA), which has often been noted in postoperative patients. For patients undergoing elective or routine (non-urgent) procedures, the FDA has recommended cessation three days prior to surgery, a plan already implemented in our pre-operative clinic since 2018. For patients undergoing emergent procedures, careful medication planning cannot be performed. Research Questions We reviewed cases of perioperative eDKA to identify clinical characteristics and factors associated with development of eDKA, and develop strategies to reduce such events.

Methods
Electronic health record (EHR) data was extracted to identify all patients between 12/1/2013 and 3/30/2021 who underwent procedures and had been prescribed an SGLT2i prior to these procedures. The resulting list was streamlined to a subset of patients who either had DKA listed as a hospital diagnosis, post-operative serum bicarbonate ≤ 16 mmol/L, or post-operative serum pH ≤ 7.20. Clinical documentation and laboratory data for these patients was reviewed to determine those with eDKA.

Results
A total of 2183 procedures (on 1307 total patients) met extraction criteria with the majority (1726, 79.1%) being non-emergent. Among the 1307 patients, 625 (47.8%) were prescribed empagliflozin, 447 (34.2%), canagliflozin, 214 (16.4%) dapagliflozin, and 21 (1.6%) ertugliflozin. Eight incidences of eDKA were noted on 8 unique patients; 5 had undergone emergent and 3 had undergone non-emergent procedures. In the 3 non-emergent cases, only 1 patient had received counseling to stop the SGLT2i three days prior to the procedure. In perioperative patients who were prescribed an SGLT2i over a six-year period, the incidence of eDKA was 0.17% for non-emergent procedures and 1.1% for emergent procedures.

Conclusions
Euglycemic DKA was rare in patients undergoing non-emergent procedures. The implementation of a pre-operative program to instruct patients to stop their SGLT2i three days pre-operatively likely contributes to this low incidence. The incidence of eDKA was notably higher in patients undergoing emergent procedures, likely due to inability to plan for temporary SGLT2i cessation. To decrease such events, recent literature has suggested considering a perioperative intravenous insulin and glucose infusion. At our institution, we are implementing a real-time monitoring system with an automated alert to the endocrinology service for hospitalized patients who have been on SGLT2i and have hyperglycemia, acidosis, or ketosis. With the anticipated increased use of SGLT2i, including in the inpatient setting, we urge hospitals and health systems to increase vigilance and develop protocols to mitigate the risk of eDKA.
Presentation: No date and time listed