Empagliflozin
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Diabetic ketoacidosis and urinary tract infection: case report A 47-year-old man developed diabetic ketoacidosis (DKA) and urinary tract infection (UTI) during treatment with empagliflozin for type 2 diabetes mellitus (T2DM) [routes, dosages and duration of treatment to reactions onsets not stated]. The man, who had a 10-year history of T2DM presented to the emergency department with several days of sore throat, nonbloody emesis, dyspnoea, poor oral intake and abdominal pain. Two weeks before, he developed an UTI. For which, the man received unspecified antibiotics and his UTI resolved. Over several months, he had made significant changes in his diet (Atkins or ketogenic diet) and lost 60lb weight. He had been receiving metformin and empagliflozin for 5 months. His previous haemoglobin A1c was 76 mmol/dL (9.1%). One month prior to the current presentation, he presented to the emergency department with weakness, intermittent chest discomfort and shortness of breath. His anion gap was 21, bicarbonate level was 13 mmol/L and pH was 7.22. He was noted to have 3+ urinary ketones with a glucose level of 7 mmol/L (127 mg/dl). He was treated with unspecified fluid therapy and some improvement was noted. All these findings were attributed to the keto diet. Eventually, he was discharged. He was recommended to increase carbohydrate intake for 2 weeks and repeat electrolytes. However, the use of empagliflozin was not identified on his medication list in the emergency department. After one week, his anion gap was 10. At the second presentation to the emergency department 24 days later, he was afebrile, tachypneic and tachycardic. His BP was 160/89mm Hg and SpO2 was 100% on room air. Investigation showed respiratory discomfort and mild abdominal discomfort to palpation. Laboratory investigation showed the following: anion gap 28, pH 6.94, bicarbonate level 5 mmol/L, 3+ urinary ketones (betahydroxybutyrate) level 8.9 mmol/L and glucose 14.9 mmol/L (269 mg/dl). He was also noted to have acute kidney injury. His Cpeptide was 0.77 nmol/L (2.3 ng/ml). A CT scan showed possible aspiration pneumonitis. However, based on the findings, he was diagnosed with diabetic ketoacidosis. He received several unspecified fluid and insulin. He was then admitted to the medical ICU. With closure of anion gap, on the following day, he was switched to insulin basal bolus regimen. Then, the metformin treatment, which was interrupted in-between, was restarted. Eventually, empagliflozin was stopped. However, he developed a new UTI as side effect of empagliflozin. Therefore, he was treated with ceftriaxone and cefalexin [cephalexin]. Later, when he was medically stable, he was discharged with plans to follow-up. Steinmetz-Wood S, et al. A Case of Diabetic Ketoacidosis in a Patient on an SGLT2 Inhibitor and a Ketogenic Diet: A Critical Trio Not to Be Missed. Case Reports in 803504509 Endocrinology 2020: 13 Aug 2020. Available from: URL: http://doi.org/10.1155/2020/8832833
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