Euglycemic Ketoacidosis due to SGLT2 Inhibitions (Flozins)

This tutorial looks at an emerging problem in medicine - iatrogenically induced eugylcemic ketoacidosis, associated with the use of SGLT2 (sodium glucose cotransporter 2) inhibitor drugs, also known as Flozins.
There is a global pandemic of metabolic disease caused by escalating ingestion of carbohydrate rich ultra processed food. This results in central obesity, hepatic steatosis (fatty liver) and insulin resistance: together these findings are labelled the "Metabolic Syndrome" (MetS). MetS is associated with systemic inflammation and atherogenesis. In many cases it progresses to Type 2 Diabetes (T2D), the majority of treatments for which increase adiposity and escalate insulin resistance. SLGT2 inhibitors are a relatively new class of drug that work by increasing excretion of ingested glucose by blocking the Sodium-Glucose symporter channel in the proximal tubule of the nephron. The result is mild natiuresis and glycosuria. These agents have been proven effective in the management of T2D and are emerging as effective treatments for other diseases such as congestive cardiac failure and nephropathy. As the name of each of these medications involves the suffix -flozin - they are commonly termed "Flozin" drugs.
One of the major problem with the use of Flozins in the community is failure to discontinue the drug when fasting or not consuming calories. Glucose will continue to be wasted, often generated by gluconeogensis, suppressing insulin secretion, resulting in lipolysis and ketosis. As blood glucose is low there is insufficient insulin present to prevent ketoacidosis. This is one of the causes of euglycemic diabetic ketoacidosis (EDKA). EDKA is associated with both ketoacidosis and hyperchloremic acidosis.
The treatment of EDKA is dextrose (to restore the Kreb's cycle and suppress ketosis) and insulin - to put some control on the metabolic system. The patient may require a couple of liters of resuscitation fluid - preferably sodium lactate solution (Hartmanns or LR). The ketosis resolves rapidly, but the acidosis resolves slowly because it is principally driven by hyperchloremia.
Patients who are being treated with SGLT2 inhibitors that are scheduled for surgery should stop taking these drugs 3 days pre-op. If they are continued inadvertently or surgery is emergent, then a dextrose infusion should be considered and ketones checked routinely.
‪@ccmtutorials‬ www.ccmtutorials.org
Description
00:10 Introduction
01:00 Review and Preview
02:00 Clinical Scenario - Elaine - T2D and fasting for urgent bowel surgery
05:40 Metabolic Disease and Metabolic Syndrome and fatty liver
09:20 Biochemistry of Insulin and Metabolic Disease
10:07 Flozins and Increased Glucose Elimination
12:05 How Do Flozins Work?
13:00 What happens in fasting or starvation in a patient treated with Flozins
15:47 Clinical Scenario - Elaine - EDKA
19:10 How to Avoid or Prevent EDKA
20:00 Clinical Scenario 2 - Gerry T2D Post Op EDKA
22:00 Simple Perioperative Management of the Patient Treated with Flozins
23:02 Review and Preview

[@alirezaparhizgar4021]

Very informative. Thanks