Empagliflozin
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Euglycaemic diabetic ketoacidosis: case report A 51-year-old woman developed euglycaemic diabetic ketoacidosis (euDKA) during treatment with empagliflozin for type-2 diabetes mellitus (T2DM). The woman was admitted to the hospital with weakness, tachypnoea, anorexia, vomiting and mild abdominal pain for 2 days. Her history was notable for peptic ulcer and T2DM, and she was an ex-smoker. Her medications included oral empagliflozin 25mg once daily, metformin/vildagliptin and omeprazole. Six days before the consultation, she had undergone elective hysterectomy due to uterine fibroids. For 2 days after surgery, she maintained a fast. She was fed on postoperative day 3 and developed episodes of vomiting on postoperative days 4 and 5. She also felt weak and fatigued on day 5, and she became febrile on day 6. Therefore, she started receiving antimicrobial treatment with piperacillin/tazobactam. At admission, on clinical examination, she found to be tachypnoic and fatigued with temperature 37.7°C, BP 160/80mm Hg, HR 105 beats/min and RR of 35 breaths/min. Her abdominal examination showed diffused tenderness, a fresh surgical incision and no focal guarding or rebound. Her urine flow rate was up to 300 mL/h, which suggested increased diuresis. No pathological findings were observed on blood and urine cultures, or abdominal ultrasound. Further laboratory work-up was found to be normal apart from an elevated WBC count and metabolic acidosis. Thereafter, she was transferred to the department of nephrology. During review of her medical history, she stated that she had been taking her anti-diabetic medications by herself. Also, she remained in a fasting condition for 48h postoperatively. Due to the severe acidosis with mildly elevated glucose levels, she was suspected to have euDKA secondary to empagliflozin. Therefore, her blood and urine samples were drawn for further ketone analyses. The urine analysis showed elevated ketones and glucose, with glycosuria. Based on her medical history, presenting symptoms and investigation, a diagnosis of empagliflozin-associated euDKA was confirmed [duration of treatment to reaction onset not stated]. Her bicarbonate level was found to be extremely low with, a mildly increased anion gap. The woman was initially infused with sodium bicarbonate over 2h, followed by unspecified fluids and insulin, based on DKA protocol. Three hours after the initiation of infusion, mild improvement in her bicarbonate level was noted. Over time, further improvement in her bicarbonate level was achieved by normal renal function. Her blood pH level normalised within 24h after the initiation of the treatment. Due to hypophosphataemia, she received phosphate infusion. Thereafter, she regained her appetite and started receiving a basal and pre-prandial insulin regimen. During that time, signs of postsurgical cellulitis were observed, which were treated with unspecified antimicrobial agents. Her empagliflozin treatment was discontinued. On day 12, she was discharged from the hospital with an anti-diabetic regimen c
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