Dapagliflozin
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Atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis: case report A 72-year-old woman developed atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis during treatment with dapagliflozin for type 2 diabetes mellitus. The woman, who had type 2 diabetes mellitus from 13 years with chronic kidney disease, presented to hospital progressively worsening weakness over the previous month and fall. Her medications included metformin, sulfonylurea and a dipeptidyl peptidase IV (DPP-4) inhibitor. Approximately 2 months prior to the current presentation, for renal protection her treatment with sulfonylurea had been switched to oral dapagliflozin [dosage not stated], by a different nephrologist. However, following initiation of dapagliflozin, she developed dizziness and progressive general weakness followed by polyuria and polydipsia. Thereafter, following a fall, she developed thoracic spine compression fracture, for which she underwent vertebroplasty. Due to persistent weakness, she again experienced a fall after 10 days and due to gradual deterioration of consciousness, she was brought to the emergency department and evaluated. She showed altered mental status with slow verbal response, lethargy and confusion. Her Glasgow Coma scale (GCS) was E3V3M5. Laboratory tests showed remarkable metabolic acidosis with a pH of 7.052, bicarbonate concentration was 6.9 mmol/L and partial pressure of CO2 was 25.3mm Hg. Additionally, her blood ketone levels were also increased (1.5 mmol/L), and she was hyperglycaemic with blood glucose levels elevated to 358 mg/dL and C-peptide level was low at 0.6 ng/mL. There was mild elevation in the C-reactive protein levels. Urinalysis demonstrated glycosuria, proteinuria and ketonuria without pyuria. A brain CT showed normal aging brain patterns. The woman was treated with IV fluids and insulin pump. Despite, she remained unconscious. Following consultation to the neurologist, metabolic encephalopathy was suspected. Following evaluation, eventually based on these clinical presentation and findings, she was diagnosed with atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis associated with dapagliflozin [duration of treatment to reaction onsets not stated]. Thus, her insulin pump therapy was continued with aggressive IV fluid treatment that resulted in improvement in her state. Her consciousness returned to the GCS score of E4V5M6 and her polyuria and polydipsia also recovered. Following closure of the anion gap, IV insulin treatment was switched to SC basal bolus insulin, and she was discharged on mixed-type insulin injection instead of dapagliflozin therapy for diabetes. Wang C-T, et al. An atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis induced by sodium-glucose cotransporter-2 inhibitors: A case report. Journal of the 803498254 Formosan Medical Association 119: 1325-1328, No. 8, Aug 2020. Available from: URL: http://doi.org/10.1016/j.jfma.2019.11.015
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