We have detected you are using Internet Explorer. To provide the best and most secure experience, please use a modern browser as we do not support Internet Explorer.

Clinical Opal #11 - SGLT2i-related DKA

Terese is a 64-year-old retired teacher who has a 12 year history of type 2 diabetes. She also has hypertension. She takes metformin 1000mg bd and irbesartan 150mg daily...

Terese presents to you today for repeat medication prescriptions and review of recent blood tests. Her HbA1c is 8.5% and has been above 8% for the past 9 months, despite increased physical activity and 2kg weight loss. Her eGFR is 62 and ACR 44 (microalbuminuria).

You are keen to add a second antihyperglycaemic medication and discuss with Terese using a SGLT2 inhibitor. You discuss common side effects, including genitourinary infections. Terese then asks about possible serious adverse events.

What is the risk of ketoacidosis in patients commencing SGLT2 inhibitors? And how can this risk be minimised?

Diabetic ketoacidosis is a rare but serious adverse effect of SGLT2 inhibitors1

In 2020, a large cohort study of new users of SGLT2 inhibitors found that the relative risk of DKA was three times higher than matched controls taking a DPP-4 inhibitor, with an absolute risk of 1 in 500 cases per year2. A recent BMJ review paper stated that the risk is highest shortly after starting the drug, with 75% of cases occurring within 6 months3.

Patients usually present with typical symptoms of DKA, including polyuria, polydipsia, nausea, abdominal pain, vomiting, and drowsiness. However, up to one third of people with SGLT2i-related ketoacidosis present with normal or only mildly elevated glucose concentrations, so called 'euglycaemic DKA'. This is an important clinical point, as the absence of osmotic symptoms and hyperglycaemia may lead to a delay in diagnosis. As well, urinary ketone levels are unreliable and it is essential to check for capillary ketones to confirm the diagnosis. 

The risk of SGLT2i-related ketoacidosis can be reduced in a number of ways. All patients commencing this class of medication should be informed of the risk, including symptoms and signs to look out for and advice around fasting and dehydrating illnesses. DKA risk is higher in people who are insulin deficient, and SGLT2 inhibitors should never be used in patients with T1DM, LADA, or diabetes secondary to pancreatic disease. Other higher risk patients include those with previous DKA, eating disorders, very low carbohydrate (ketogenic) diet, alcohol or drug misuse, and low BMI.

References

1. Markey AG, Scott TA, Killen JC, Venter JA. Sodium–glucose co-transporter 2 inhibitors: Think twice about diabetic ketoacidosis. Aust J Gen Pract. 2018 Apr;47(4):223-225. doi: 10.31128/AFP-09-17-4348. PIMD: 29621864.

2. Douros A, Lix LM, Fralick M, Dell'Aniello S, Shah BR, Ronksley PE, Tremblay É, Hu N, Alessi-Severini S, Fisher A, Bugden SC, Ernst P, Filion KB; Canadian Network for Observational Drug Effect Studies (CNODES) Investigators. Sodium-Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis : A Multicenter Cohort Study. Ann Intern Med. 2020 Sep 15;173(6):417-425. doi: 10.7326/M20-0289. Epub 2020 Jul 28. PMID: 32716707.

3.  Musso G, Saba F, Cassader M, Gambino R. Diabetic ketoacidosis with SGLT2 inhibitors BMJ 2020; 371 :m4147 doi:10.1136/bmj.m4147


The Medcast Diabetes in General Practice.

Over recent years, there have been a number of significant changes in the approach to screening, diagnosis, assessment and management of diabetes in primary care. 

The Medcast 'Diabetes in General Practice' course will cover the latest in research and practice updates in this field.  The course was primarily written by Dr Justin Coleman, former editor of the Diabetes Management Journal and co-editor of Murtagh General Practice.

This course is also available as part of the GP Education Bundle which provides a triennium worth of CPD.

In addition to the Diabetes in General Practice course, the bundle also provides access to the popular Hot Topics GP update series, Emergencies in General Practice and much more. Click here to find out more.

{{commentCount}} comment(s). You must be logged in and AHPRA verified to view and comment. LOG IN
Dr Simon Morgan

Dr Simon Morgan

Simon is a GP and Medical Educator based in Newcastle, NSW.

View more

The latest healthcare news from medcast

What makes a mental health app work?
What makes a mental health app work?

Clinicians I talk to often say that they recommend mental health apps all the time, but they find that even the most enthusiastic users seem to disengage pretty quickly.

GP Educational Intervention Improves Patient Care and My Health Record Usage with Potential to Save Government Millions
GP Educational Intervention Improves Patient Care and My Health Record Usage with Potential to Save Government Millions

A two-year study titled CHIME-GP was carried out by Medcast and the University of Wollongong. It has shown that educating GPs about potentially inappropriate or unnecessary medicines, imaging and pathology test ordering in the context of using the My...

More than a race: Medcast takes on the Shitbox Rally – Autumn 2022
More than a race: Medcast takes on the Shitbox Rally – Autumn 2022

From Wollongong, NSW to Mackay, QLD in 7 days. Medcast’s own team, Tyre Kickers, are taking on Shitbox Rally – Autumn 2022.

Clinical Opal #11 - SGLT2i-related DKA
Clinical Opal #11 - SGLT2i-related DKA

Terese is a 64-year-old retired teacher who has a 12 year history of type 2 diabetes. She also has hypertension. She takes metformin 1000mg bd and irbesartan 150mg daily...

Have you lost your mojo?
Have you lost your mojo?

I’m pretty sure I’ve lost mine. I lost it in the early part of 2021 and haven’t laid eyes on it since.

Promoting reproductive choice in primary care
Promoting reproductive choice in primary care

The Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS) - a network for professionals working with women to optimise reproductive health

How Doctors Think
How Doctors Think

In this short video from the 2022 'Not to be missed' webinar series, Dr Simon Morgan provides some insights into how Doctors think.

Are we all ok?
Are we all ok?

Often OK is the very best I can do (especially lately), and I try to be grateful for that, but wouldn’t it be nice to be more than OK, to be flourishing, for a little more of the time! I hope I don’t have to wait for the world to be a better place be...

Clinical Opal #10 - Pre-conception care
Clinical Opal #10 - Pre-conception care

Kelly, aged 28, presents for an appointment as she is planning a pregnancy with her husband. She has no significant medical history, is nulliparous, is a non-smoker, has normal body weight, maintains a healthy diet and exercise routine, and has a con...

How connecting to my Aboriginality helps me stay strong
How connecting to my Aboriginality helps me stay strong

Being connected to your Aboriginal heritage can bring fulfilment and a sense of identity and culture but what about wellbeing?

Navigating the consultation
Navigating the consultation

At the core of general practice is the consultation.  In its simplest form, the consultation can be regarded as the sharing of information between patient and doctor in order to facilitate both a common understanding and a plan of management.

Clinical Opal #9 - 64 year old with fever and rigors
Clinical Opal #9 - 64 year old with fever and rigors

Joan is a 64-year-old hospital cleaner who presents to you one morning feeling 'dreadful'. Joan has a past history of well controlled diabetes and takes metformin 500mg bd.

Blended care – the future of therapy?
Blended care – the future of therapy?

Psychologists and their clients are perceiving online therapy in a new light since the pandemic. Although face-to-face therapy is once again possible, psychologists are opting for a mix of in-person and online therapy as the demand for care grows. Mo...

Clinical Opal #8 - Myeloma
Clinical Opal #8 - Myeloma

Bob Georgiou, a 66-year-old retired university lecturer, presents to you with vague aches and pains, weight loss of a few kilograms and fatigue for the past couple of months.

The dilemma of treating the ones we love
The dilemma of treating the ones we love

As a health professional, we’re always going to be faced with the professional and personal dilemma of where and when to draw the line when it comes to advice or treatment of loved ones.

Clinical reasoning and the KFP exam
Clinical reasoning and the KFP exam

In our day-to-day work as a GP, we undertake clinical reasoning with nearly every patient, mostly subconsciously. However, in preparation for the KFP exam, it can be helpful to deconstruct the clinical reasoning process. Hence this blog!

Non-adherence to thromboprophylaxis prescribing in general practice – the views of GPs
Non-adherence to thromboprophylaxis prescribing in general practice – the views of GPs

Last year, I conducted a series of interviews with GPs in order to understand their experiences with anticoagulation management in patients with atrial fibrillation (AF).

What is it about New Year’s Resolutions?
What is it about New Year’s Resolutions?

It’s that time of year again where some of us convince ourselves that we’re going to “definitely” stick to those new year’s resolutions….

Summer reading
Summer reading

There's something special and therapeutic about reading. A Summer read encapsulates so much more than just words printed on paper. Dr Jan Orman

How Christmas day hurts our brains
How Christmas day hurts our brains

Did you know our brains work overtime during stressful times. It’s likely that the holiday period will spark some serious brain activity!

Join Medcast. It's free and you'll get instant access to essential healthcare news, research and more.

Already a member? Log In