C J Van Niekerk, MD, J D Wallace, MD, M C Takata, MD, R C Yu, MD. Scripps Green Hospital
Background: Approximately 200,000 people undergo bariatric surgery annually. Of these, many have non-insulin dependent diabetes mellitus (NIDDM) frequently managed with sodium/glucose cotransporter 2 (SGLT-2) inhibitors such as canagliflozin. SGLT-2 inhibitors have been associated with ketoacidosis, even when serum glucose levels are normal. We performed a literature review and describe a case of euglycemic diabetic ketoacidosis (eDKA) in a 52 year old male, taking canagliflozin preoperatively, after an uncomplicated laparoscopic roux-en-Y gastric bypass (LRYGB).
Methods: A Pubmed search for eDKA in bariatric surgery patients taking SGLT-2 inhibitors was performed.
Results: Two previous cases of eDKA after bariatric surgery were found, of which only one actually met the definition of euglycemia. Our case describes a 52-year-old obese male with a body mass index of 45 kg/m2 and NIDDM who underwent an uncomplicated LRYGB. Per institution protocol he was started on a low carbohydrate diet 5 days prior to surgery. He was instructed to continue all medications, including metformin 1000 mg twice daily and canagliflozon 300 mg daily until the day prior to surgery.
Postoperatively he developed a leukocytosis and an anion gap metabolic acidosis. Although he was completely asymptomatic, serum studies revealed carbon dioxide of 9 mmol/L, glucose of 112 mg/dL and a beta-hydroxybutyrate of 49.7 mg/dL. The anion gap was calculated to be 23. A urinalysis was significant for a urine glucose of 500 mg/dL with urine ketones of more than 80 mg/dL. Further workup included undetectable acetaminophen and salicylate levels and a normal lactic acid.
Given the high anion gap metabolic acidosis, markedly elevated beta-hydroxybutyrate and additional studies indicating no other unmeasured anions, the diagnosis of eDKA was made. The patient was started on aggressive IV hydration and an insulin drip. The acidosis corrected and he was discharged home two days after the diagnosis.
Conclusions: SGLT-2 inhibitors such as canagliflozin, represent a relatively new class of oral hypoglycemic that have been rarely associated with eDKA. The incidence of postoperative eDKA is likely higher than that reported in the literature specifically in patients undergoing bariatric surgery as a consequence of depleted glycogen stores and surgical stress. It is of the utmost importance that surgeons learn to recognize eDKA. Also, guidelines must be developed in order to minimize adverse events in surgical patients that have been prescribed SGLT-2 inhibitors.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 77819
Program Number: P177
Presentation Session: Poster (Non CME)
Presentation Type: Poster
