Obesity Abstracts (2020) 2 CD1.2 | DOI: 10.1530/obabs.02.CD1.2

A case of refractory euglycemic diabetic ketoacidosis post elective bariatric surgery

Huma Humayun Khan, Ester Dubiwa, Zaw Ye Htet, Theingi Aung & Foteini Kavvoura


Centre for Diabetes & Endocrinology, Royal Berkshire NHS Foundation Trust, Reading, UK.


SGLT2 inhibitors (SGLT2Is) are increasingly prescribed for patients with Type 2 Diabetes (T2D) as they are associated with cardiovascular benefit and weight loss with low risk of hypoglycaemia. However, in the last few years, euglycemic ketoacidosis has emerged as a recognized complication of treatment with SGLT2I. The challenge lies in delayed recognition and treatment as it can be easily overlooked due to the conspicuous absence of marked hyperglycaemia. Ketoacidosis can also occur in starvation, low calorie diet, pregnancy and alcohol excess. Herein we present a case of a 54-year-old patient with T2D on empagliflozin, who presented with euglycemic ketoacidosis (euDKA) within 24 h following elective bariatric surgery. Pre-operatively, he had undergone liver shrinkage diet (LSD) for 2 weeks and continued empagliflozin contrary to clinical instructions. His ketonemia proved unusually refractory to DKA protocol, complicated by episodes of hypoglycaemia and hypotension. Ketosis worsened on weaning of DKA treatment and he required ITU admission. His ketonemia took 72 h to resolve. He mistakenly continued to take empagliflozin on discharge, leading to continued ketonemia (with no acidosis) for 2 weeks post-op, until he was once again advised to stop, during his diabetes post-op review. This case highlights the multifactorial causes of euDKA: treatment with SGLT2I throughout LSD, and prolonged starvation peri-operatively. It exemplifies the importance of stopping SGLT2I during LSD, as well as post bariatric surgery. The current recommendation is to withhold SGLT2i 24 h prior to surgery, given their half-life is 12.5 h. In agreement with a recently published review of euDKA cases following surgical procedures, we feel that there is a need to revise the current recommendation and develop a comprehensive guideline for perioperative management for patients on SGLT2I, in particular as these drugs are likely to be used more widely in Type 1 diabetes and heart failure patients in the near future. Moreover, it is important to maintain a high index of suspicion for euDKA in patients with T2D on SGLT2I, especially in perioperative setting. Finally, this case emphasizes the importance of preoperative patients’ and healthcare professionals’ education and close follow-up by the diabetes team.

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