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Sodium–glucose cotransporter-2 inhibitor–associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery

      Abstract

      Background

      Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with use of sodium–glucose cotransporter-2 inhibitors (SGLT2i). This risk is further pronounced in the perioperative period. There is no consensus for when SGLT2i should be held preoperatively, and recommendations from various organizations have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association guidelines. Further study of patients with perioperative euglycemic DKA is required to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents.

      Methods

      In this retrospective, single-centre case series we examined 4 patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent semiurgent surgery. We characterized their clinical course, predisposing factors and treatment characteristics.

      Results

      The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24 hours after surgery. The fourth patient developed euglycemic DKA on postoperative day 3 in the context of significant hypovolemia and exhibited potential signs of protracted SGLT2i action at 7 days since the last dose.

      Conclusions

      The duration of SGLT2i action and risk for DKA is variable and complex. Providers should hold SGLT2i at least 3 days before elective major surgery, with potentially longer times in high-risk patients. Careful vigilance should be used for perioperative DKA development in all patients recently exposed to SGLT2i.

      Résumé

      Introduction

      L’acidocétose diabétique (ACD) euglycémique est une complication potentiellement mortelle associée à l’utilisation des inhibiteurs du cotransporteur sodium-glucose de type 2 (iSGLT2). Ce risque est davantage prononcé durant la période périopératoire. Il n’existe pas de consensus pour dire jusqu’à quel moment avant l’opération les iSGLT2 devraient être maintenus, mais dans les plus récentes lignes directrices de l’Association américaine du diabète, les recommandations provenant des différentes organisations sont passées de 1 jour à 3-4 jours. Une étude plus approfondie au sujet des patients qui ont une ACD euglycémique en phase périopératoire est nécessaire pour mieux cerner le moment optimal de l’interruption en phase préopératoire des iSGLT2.

      Méthodes

      Dans la présente série rétrospective unicentrique de cas, nous nous sommes penchés sur 4 patients, qui avaient eu une ACD euglycémique en phase postopératoire après un pontage aortocoronarien, dont 3 avaient subi une intervention chirurgicale semi-urgente. Nous avons décrit l’évolution clinique des patients, les facteurs prédisposants et les caractéristiques du traitement.

      Résultats

      Les iSGLT2 avaient été maintenus de 1 à 5 jours avant l’opération, soit des durées depuis la dernière dose avant l’intervention chirurgicale de 54, 79, 80 et 151 heures. Trois patients avaient subi une intervention chirurgicale semi-urgente, et 1 patient avait eu une intervention chirurgicale non urgente. Trois patients avaient reçu un diagnostic d’ACD euglycémique dans les 24 heures après l’intervention chirurgicale. Le 4e patient avait eu une ACD euglycémique le 3e jour après l’opération dans le contexte d’une hypovolémie significative et avait montré des signes potentiels d’action prolongée des iSGLT2 7 jours après la dernière dose.

      Conclusions

      La durée d’action des iSGLT2 et le risque d’ACD sont variables et complexes. Les prestataires de soins de santé devraient maintenir les iSGLT2 au plus tard 3 jours avant l’intervention chirurgicale lourde non urgente et potentiellement des durées plus longues chez les patients exposés à un risque élevé. On devrait faire preuve d’une grande vigilance en présence d’ACD en phase périopératoire chez tous les patients récemment exposés aux iSGLT2.

      Keywords

      Mots clés

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