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DKA and SGLT-2 statement issued

By Editor
8th December 2016
Latest news

The increased risk of diabetic ketoacidosis (DKA) in both type 1 and type 2 diabetes from SGLT-2 inhibitors has been highlighted by a leading body of diabetes consultants.

The Association of British Clinical Diabetologists (ABCD) has issued a position statement on DKA and SGLT-2s, which reduce the amount of glucose in blood as well as lowering the amount of glucose being absorbed in the kidneys so that it is passed out in the urine.

The complication has been reported in people with diabetes taking SGLT-2 inhibitor drugs in clinical trials and in daily life, particularly where insulin is used as a treatment.

The use of SGLT-2 inhibitors is associated with a small but increased risk of diabetic ketoacidosis in both type 1 and type 2 diabetes, according to ABCD.

The organisation is urging healthcare professionals to exercise caution when using SGLT-2 inhibitors in people at high risk of ketoacidosis due to other reasons like dehydration, stress, admission into hospital for elective surgery, trauma, acute medical illness or any other catabolic state.

The position statement concluded: “In general, the rate and prevalence of DKA in people with type 2 diabetes taking SGLT-2 inhibitors is very low and does not warrant a change in practice in the use of these agents.

“In patients with type 1 diabetes or insulin treated type 2 diabetes it would make pragmatic sense to anticipate and monitor for possible DKA in situations which are known to precipitate metabolic decompensation (injury, infections, stressful events and catabolic states).

“There should be prompts to identify patients attending emergency departments or medical admissions units that are prescribed SGLT-2 inhibitors to warn of the possibility of euDKA. SGLT-2 inhibitors should be discontinued in patients that have developed DKA and should not be restarted unless a clear alternative cause of DKA is identified.”

Key messages from ABCD position statement
The use of SGLT-2 inhibitors is associated with a small but increased risk of diabetic ketoacidosis in both type 1 and type 2 diabetes.
Caution should be exercised when using SGLT-2 inhibitors in patients who are at high risk of ketoacidosis due to other reasons like dehydration, stress, admission into hospital for elective surgery, trauma, acute medical illness or any other catabolic state.
Blood glucose levels may not be elevated in SGLT-2 inhibitor associated ketoacidosis and the diagnosis can be missed.
Treatment of SGLT-2 inhibitor associated ketoacidosis may require a variable, rather than a fixed, rate intravenous insulin infusion and intravenous dextrose to prevent hypoglycaemia.
The use of SGLT-2 inhibitors in type 1 diabetes, outside of clinical trials, is not recommended.

The ABCD position statement also concluded: “The absolute risk of DKA with SGLT-2 inhibitors is unclear but the current reported incidence of SGLT-2 inhibitor associated DKA is likely to be an underestimate due to the unusual presentation of these patients and a lack of general awareness of this complication.”

The US Food and Drug Administration issued a safety communication following 20 cases of DKA in people receiving the drug, prompting a position statement by the American Association of Clinical Endocrinologists and American College of Endocrinology.

The ABCD position statement is available at: http://www.diabetologists-abcd.org.uk/Position_Papers/ABCD_DKA_SGLT2.pdf.

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