The reason I placed these notes in my blog instead of just placing a link is that by copying them they can function as study notes [the whole blog is essentially just my study notes] and doing this helps me remember the topic.
The first part of the post is from Diabetic Ketoacidosis and is excellent.
But for me the second part of the post from Euglycemic DKA: It’s not a Myth introduced me to information which could be critical and that is – that a normal blood sugar does not always rule out diabetic ketoacidosis:
Clinical Take Home Point: In patients with diabetes mellitus, on a SGLT-2 inhibitor and/or carbohydrate food restriction, who present with nausea/vomiting, fatigue, or the development of a metabolic acidosis, checking a urine and/or serum ketones is critical to not miss a case of euDKA.
All that follows is from Diabetic Ketoacidosis by Diabetes Education Online:
Diabetic Ketoacidosis (DKA) – a condition brought on by inadequate insulin – is a life-threatening emergency usually affecting people with type 1 diabetes. Although less common, it also can happen when you have type 2 diabetes.
DKA is usually, but not always, signaled by high blood sugar levels. The important fact to remember is that without enough insulin, the body cannot burn glucose properly and fat comes out of fat cells. As a consequence the excess fat goes to the liver and glucose builds up in the bloodstream. The liver makes ketoacids (also known as ketones) out of the fat. Before long, the body is literally poisoning itself with excess glucose and ketoacids.
What causes DKA?
A lack of insulin usually due to:
- Unknown or newly diagnosed cases of type 1 diabetes
- Missed or inadequate doses of insulin, or spoiled insulin
- Infection
- Steroid medications
- An extremely stressful medical condition
DKA is rare in type 2 diabetes – but can develop if someone with type 2 diabetes gets another serious medical condition. Examples of medical conditions associated with DKA in type 2 diabetes are severe infections, acute pancreatitis (inflammation of the insulin producing organ, the pancreas), and treatment with steroids. [Be sure to review Euglycemic DKA: It’s not a Myth by Rebel EM. It has critical information]
Symptoms of DKA include:
- Nausea, vomiting
- Stomach pain
- Fruity breath – the smell of ketoacids
- Frequent urination
- Excessive thirst
- Weakness, fatigue
- Speech problems, confusion or unconsciousness
- Heavy, deep breathing
How do you know if you have DKA?
Check your blood or urine for ketones. And if the test is positive, you will need immediate medical care. Treatment includes aggressive intravenous (IV) insulin and fluid replacement.
if you have dka, get to a hospital immediately.
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Euglycemic diabetic ketoacidosis (DKA with a blood sugar of less than 200 mg/dl) can occur in both type 1 and type 2 diabetes – see Euglycemic DKA: It’s not a Myth from Rebel EM for excellent post. What follows is from that post:
Euglycemic DKA is a rare entity that mostly occurs in patients with type 1 diabetes, but can possibly occur in type 2 diabetes as well. The exact mechanism of euDKA is not entirely known, but has been associated with partial treatment of diabetes, carbohydrate food restriction, alcohol intake, and inhibition of gluconeogenesis. euDKA, can also be associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitor medications. These medications first came onto the market in 2013 and are FDA approved for the treatment of type 2 diabetes, however many physicians use them off-label for type I diabetes due to their ability to improve average glucose levels, reduce glycemic variability without increasing hypoglycemia, and finally promote weight loss.
What are the Names of the SGLT-2 Inhibitors?
- Ipragliflozin (Suglat) – Approved in Japan
- Dapagliflozin (Farxiga) – 1st SGLT2 Inhibitor Approved; Approved in US
- Luseogliflozin (Lusefi) – Approved in Japan
- Tofogliflozin (Apleway; Deberza) – Approved in Japan
- Canagliflozin (Invokana) – Approved in US & Canada
- Empagliflozin (Jardiance) – Approved in US
Discussion:
- euDKA could be completely missed if just looking at the serum blood glucose alone. This could lead to worse outcomes for patients not started on treatment
- The exact incidence of euDKA in patients taking SGLT-2 inhibitors is really unknown, as this entity may be under reported or even completely missed
- The treatment of euDKA will be nearly identical to DKA:
- IVF: Treat dehydration; In addition to balanced crystalloids, may need to start fluids with dextrose sooner in the treatment process, due to the serum blood glucose already being low (i.e. <200mg/dL),
- IV Insulin: Close the anion gap and reverse the metabolic acidosis
Clinical Take Home Point: In patients with diabetes mellitus, on a SGLT-2 inhibitor and/or carbohydrate food restriction, who present with nausea/vomiting, fatigue, or the development of a metabolic acidosis, checking a urine and/or serum ketones is critical to not miss a case of euDKA.
