Additional Warning on SGLT2 Inhibitor Use and DKA Threat in COVID-19

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Use of sodium-glucose cotransporter 2 (SGLT2) inhibitors throughout acute COVID-19 sickness raises the chance for euglycemic diabetic ketoacidosis (euDKA), a brand new case collection suggests.

5 sufferers with type 2 diabetes who have been taking SGLT2 inhibitors offered in DKA regardless of having glucose ranges beneath 300 mg/dL. The report was revealed on-line final month in AACE Medical Case Reviews by Rebecca J. Vitale, MD, and colleagues at Brigham and Ladies’s Hospital, Boston, Massachusetts.

“A cluster of euglycemic DKA instances at our hospital in the course of the first wave of the pandemic means that sufferers with diabetes taking SGLT2 inhibitors could also be at enhanced threat for euDKA once they contract COVID-19,” senior creator Naomi D.L. Fisher, MD, informed Medscape Medical Information.

Fisher, an endocrinologist, added: “This complication is preventable with the straightforward measure of holding the drug. We’re hopeful that widespread affected person and doctor schooling will forestall future instances of euDKA as COVID-19 infections proceed to surge.”

These instances underscore suggestions published early within the COVID-19 pandemic by a global panel, she famous.

“Sufferers who’re acutely in poor health with nausea, vomiting, stomach ache, or diarrhea, or who’re experiencing lack of urge for food with decreased meals and fluid consumption, ought to be suggested to carry their SGLT2 inhibitor. This treatment shouldn’t be resumed till sufferers are feeling higher and consuming and ingesting usually.”  

Alternatively, “If sufferers with asymptomatic or delicate COVID-19 an infection are in any other case effectively, and are consuming and ingesting usually, there isn’t a proof that SGLT2 inhibitors should be stopped. These sufferers ought to monitor [themselves] carefully for worsening signs, particularly leading to poor hydration and vitamin, which might be motive to discontinue their treatment.” 

Pay Particular Consideration to the Aged, These With Issues

Nonetheless, particular consideration ought to be given to aged sufferers and people with medical circumstances recognized to extend the probability of extreme an infection, like heart failure and chronic obstructive pulmonary disease, Fisher added.

The SGLT2 inhibitor class of medicine causes important urinary glucose excretion, and they’re additionally diuretics. A lower in out there glucose and quantity depletion are most likely each vital contributors to euDKA, she defined.

With COVID-19 an infection the euDKA threat is compounded by a number of mechanisms. Most instances of euDKA are related to an underlying state of hunger that may be triggered by vomiting, diarrhea, lack of urge for food, and poor oral consumption.

As well as — though not but recognized for sure — SARS-CoV-2 can also be toxic to pancreatic beta cells and thus scale back insulin secretion. The maladaptive inflammatory response seen with COVID-19 can also contribute, she mentioned.  

The sufferers within the present case collection have been three males and two ladies seen between March and Could 2020. They ranged in age from 52 to 79 years.

None had a previous historical past of DKA or any recognized diabetes problems. In all of them, antihyperglycemic drugs, together with SGLT2 inhibitors, have been stopped on hospital admission. The sufferers have been initially handled with intravenous insulin, after which subcutaneous insulin after the DKA prognosis.

Three of the sufferers have been discharged to rehabilitation services on hospital days 28-47 and one (age 53 years) was discharged dwelling on day 11. The opposite affected person additionally had hypertension and nonalcoholic steatohepatitis. He developed acute respiratory misery, was intubated, and died on hospital day 18. He was 52 years outdated, the youngest of the group.   

The authors have reported no related monetary relationships.

AACE Clin Case Rep. Printed on-line December 28, 2020. Full text

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