Empagliflozin
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Euglycaemic ketoacidosis: case report A 71-year-old man developed euglycaemic ketoacidosis during treatment with empagliflozin for type 2 diabetes mellitus. The man, who had stage IV lung adenocarcinoma, presented with symptomatic hypercalcaemia treated with a single dose of zoledronic acid. His medical history was significant for invasive urinary bladder carcinoma, ureteric ileostomy and type 2 diabetes mellitus. He had been receiving metformin, and additionally started receiving empagliflozin 10mg once daily [route not stated] 3 months prior to the presentation for type 2 diabetes mellitus. On presentation, he reported short term memory and constipation. Following clinical examination, he was also diagnosed with hospital-acquired pneumonia, for which, he was treated with unspecified anticoagulant and was escalated to high flow nasal prongs for ventilator support. His CT pulmonary angiogram showed left-sided pleural effusion, straightening of the ventricular septum indicating right heart strain and bilateral pulmonary emboli. Transthoracic echocardiogram confirmed the right heart strain with pulmonary artery pressure of 42mm Hg and showed impaired systolic function and dilated right ventricle. Despite high flow oxygen supplementation, his tachypnoea persisted. An arterial blood gas analysis showed an anion gap acidosis (base excess -11 mmol/L, albumin-corrected anion gap 19.9 mmol/L, partial pressure of CO2 25.7mm Hg, bicarbonate 13.6 mmol/L and pH 7.343), partial pressure of oxygen 75.3mm Hg, beta-glucosidase leukocyte 4.7 mmol/L, bedside capillary glucose 5.1 mmol/L and ketones 7.4 mmol/L consistent with euglycaemic ketoacidosis [time to reaction onset not stated]. The man’s empagliflozin was continued and he was treated with glucose [dextrose] and insulin. For further management, he was transferred to the ICU. A repeat arterial blood gas analysis performed after 12 hours and showed base excess -3.6 mmol/L, partial pressure of CO2 34.5mm Hg, bicarbonate 20.5 mmol/L, pH 7.391, partial pressure of oxygen 70.9mm Hg, beta-glucosidase leukocyte 6.8 mmol/L and ketones 0.1 mmol/L. He continued receiving glucose and insulin until his metabolic acidosis resolved and blood ketone level normalised with normoglycaemia. After 20 hours, laboratory tests showed pH 7.384, partial pressure of oxygen was 34.3mm Hg, partial pressure of CO2 was 38mm Hg, bicarbonate 22.2 mmol/L, base excess -2.1 mmol/L, beta-glucosidase leukocyte 7 mmol/L and ketones 0.3 mmol/L. On day 6 of admission, he underwent pleurocentesis with mild improvement in his oxygen requirement. On day 7 of admission, he was discharged from the ICU. At the time of discharge, his blood ketone level normalised and his beta-glucosidase leukocytes were controlled on insulin treatment. He was on oxygen supplementation for his underlying pneumonia; however, his tachypnoea had recovered. The heparin treatment was changed to enoxaparin sodium [clexane] for bilateral pulmonary emboli. His chest X-ray showed stable appearance in his bilateral pleural effusions at the time
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