Introduction

Sodium Glucose co-transporter inhibitors (SGLT2i) are a new class of oral hypoglycaemic agents used in the treatment of Type 2 diabetes. On May 15, 2015 the US Food and Drug Administration (FDA) issued a warning that these drugs may lead to DKA. We report the first two cases of SGLT2i associated DKA in Australia.

Case 1

A 40 year old male presented to a South Queensland Tertiary facility in March 2015 with epigastric and central abdominal pain for 3 days. He had associated nausea, but no vomiting or diarrhoea.

His background included T2DM, diagnosed 2 yrs ago, depression and dyslipidaemia. His medications included Rosuvastatin, Sertraline, Quetiapine, Metformin/Sitagliptin 1000/50 mg BD, and had commenced Dapagliflozin 10mg OD 4 months prior.

Clinical examination did not reveal peritonitis or obstruction, and abdominal Xray suggested constipation. His bloods tests (Table 1) confirmed DKA. Acidosis did not correct initially with IV saline, but quickly resolved with glucose-insulin infusion.

Case 2

A 65 year old female presented to a North Queensland hospital in May 2015 with 3 days of thirst, fatigue, nausea and breathlessness. Her past medical history included Type 2 diabetes, hypothyroidism, hypertension and dyslipidaemia, and sleeve gastrectomy 7 months ago. There was no prior history of DKA.

Her medications included Perindropril, Rosuvastatin, Thyroxine, Lantus 18u nocte, Novorapid 4u with meals, Metformin 1g XR OD and Dapagliflozin 10 mg OD, which she had commenced 3 months prior to this presentation.

Her blood test results (Table 1) confirmed DKA. She was treated with IV fluids and insulin and made an uneventful recovery. No precipitant was identified.

Summary

The possible mechanism for Dapagliflozin induced Diabetic ketoacidosis is unclear. However it has been reported in post-marketing Adverse Drug Event Reporting in USA, and also a phase 2 trial of Tofogliflozin reported ketosis¹. The FDA report² indicates that over half the cases did not have an identified trigger and an atypical feature that DKA in this group had only mild hyperglycaemia.