SGLT2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis In Acute Stroke Patients

초록

Diabetic ketoacidosis (DKA) is usually associated with severe hyperglycemia and dehydration in type 1 diabetes mellitus. Howeverm it can occur rarely in the setting of normal glucose concentrations, known as euglycemic DKA, which was known to develop mostly in individuals with type 1 diabetes, or pregnant diabetic women. Sodiumglucose cotransporter 2 (SGLT2) inhibitors are new oral hypoglycemic drugs and have a pronounced glucoselowering effect with a low risk of hypoglycemia. These medication also could reduces congestive heart failure and cardiovascular diseases. We present two cases with type 2 diabetes mellitus hospitalized for acute stroke, who developed empagliflozin-associated euglycemic diabetic ketoacidosis. A 69-year-old woman with the history of type 2 diabetes mellitus(DM) who presented with left midbrain infarction during surgery for intertrochanter fracture in other hospital. On admission, she had euglycemic DKA and she had the history of medication of empagliflozin for one month. The Hba1c level was 12.1% and the ketone serum level of ketone body was over 9600 mmol/L. After stopping empagliflozin, ketone bodies decreased to less than 200 mmol/L. The second patient, a 74-year-old woman with DM history presented with right IC infarction. Initial Hba1c was 9.9% but she did not take the medication for DM control. We tried oral medication including empagliflozin and the serum glucose level improved. However,she suffered from acute myocardiac infarction. After PCI, she had euglycemic DKA. Serum level of ketone body was over 7400 mmol/L and serum glucose level was below 220 mg/dL. After hydration and stopping empagliflozin, the laboratory findings improved. Early recognition of this medical emergency like DKA and timely intervention can reduce the consequences of serious complication. However, this form of DKA could be missed by normal serum glucose levels. Clinical considerations to ensure safe SGLT2 inhibitor therapy should include approp