Diabetic ketoacidosis in patients treated with SGLT2 inhibitors: experience at a tertiary hospital

Purpose Diabetic ketoacidosis (DKA) is a rare and life-threatening complication in patients with diabetes. Sodium–glucose co-transporter-2 inhibitors (SGLT2i) have rarely been associated with ketoacidosis. The aim of this retrospective study was to investigate DKA episodes occurring after SGLT2i treatment and to compare them to DKA episodes due to other causes. Methods The medical records of the years 2018–2020 related to clinical and biochemical characteristics and to treatment of six patients with DKA due to SGLT2i were reviewed. They were compared to those of 12 patients with DKA due to other causes. Results On admission, the most common symptom was abdominal pain. Glucose levels (median, min–max) were lower in patients with SGLT2i-induced DKA compared to those with DKA due to other causes (229 (150–481) vs. 458.5 (332–695) mg/dl, p = 0.007), whereas no statistical difference was observed in HbA1c and in the severity of DKA (pH, HCO 3 , CO 2 , and anion gap). The duration of insulin infusion (41 (33–124) vs. 21.50 (11–32) h, p < 0.001) and the time required until DKA resolution (39 (31–120) vs. 19 (9–28) h, p < 0.001) were higher in patients with SGLT2i-induced DKA than those with DKA due to other causes. In addition, there were increased fluid requirements (14 (8–22.75) vs. 5.5 (2–24) L, p = 0.013) and longer hospitalization time (11 (6–22) vs. 5.5 (2–14) days, p = 0.024) in patients with SGLT2i-induced DKA. No statistically significant differences were observed in total intravenous insulin and potassium administration until DKA resolution. Conclusions Patients with SGLT2i-induced DKA had lower serum glucose levels on admission and required increased fluid administration and longer time to recover from acidosis compared to patients with DKA from other causes.