E-Poster Presentation ESA-SRB-ANZBMS 2021

Euglycaemic ketoacidosis post COVID vaccination in patient with diabetes mellitus on SGLT2 inhibitor (#401)

Mike Lin 1 , Kenneth W Ho 1 2
  1. Department of Diabetes and Endocrinology, Ryde Hospital, Ryde , NSW, Australia
  2. Department of Clinical Medicine, Macquarie University Hospital, Macquarie University, NSW, Australia

Case presentation
58-year-old male with type 2 diabetes mellitus on empagliflozin, gliclazide and linagliptin presents to emergency department with 1 day of nausea, vomiting and upper abdominal pain. He was started on empagliflozin 4 days prior and received first dose of Oxford-AstraZeneca vaccine 2 days prior. Bloods showed severe metabolic acidosis, BGL 6.1mmol/L, ketones 3.8mmol/L, lactate 2.2mmol/L and Hba1c 11.2%. Inflammatory markers were normal. Transferred to ICU for insulin infusion and intravenous fluids. After resolution of euglycaemic DKA patient was discharged home on ryzodeg insulin, linagliptin and gliclazide. Islet cell antibodies were negative making diagnosis of LADA or type 1 diabetes unlikely. On follow up one month later patient remained insulin dependent.

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Discussion
Euglycaemic DKA (euDKA) is rare but serious complication associated with SGLT2 inhibitors use in patients with diabetes mellitus. Common triggers include prolonged fasting, low caloric intake, alcohol use and intercurrent illness. COVID-19 infection causes euDKA in patients on SGLT2 inhibitors1. SARS-CoV-2 utilises the ACE-2 receptor to enter islet cells leading to direct cellular destruction. The decrease in insulin production predisposes to euDKA while acidosis also favours entry and replication of the virus2.

We report the first case of euDKA shortly after administration of a COVID-19 vaccine. The Oxford-AstraZeneca vaccine uses a viral vector to deliver antigen coded genetic material and does not contain any live virus. MEDLINE search reveals one case report of HHS and newly diagnosed diabetes post Pfizer vaccine3. COVID vaccines have also been shown to induce transient hyperglycaemia4. SGLT2 inhibitors does not confer significant protection during COVID-19 syndrome5. Reactions to COVID vaccines are common and include gastrointestinal symptoms such as nausea and reduced intake6. Clinicians need to be vigilant for development of euDKA and it may be necessary to advise withholding SGLT2 inhibitors two days prior to receiving COVID vaccine and to self-monitor BGLs.

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  2. Vitale R, Valtis Y, McDonnell M, Palermo N, Fisher N. Euglycemic diabetic ketoacidosis with COVID-19 infection in patients with type 2 diabetes taking SGLT2 inhibitors. AACE Clinical Case Reports. 2021;7(1):10-13.
  3. Abu-Rumaileh M, Gharaibeh A, Gharaibeh N. COVID-19 vaccine and hyperosmolar hyperglycemic state. Cureus. 2021;13(3).
  4. Mishra A, Ghosh A, Dutta K, Tyagi K, Misra A. Exacerbation of hyperglycemia in patients with type 2 diabetes after vaccination for COVID19: Report of three cases. Diabetes & Metabolic Syndrome. 2021;15(4):102151.
  5. Kosiborod M, Esterline R, Furtado RH, Oscarsson J, Gasparyan S, Koch G et al. Dapagliflozin in patients with cardiometabolic risk factors hospitalised with COVID-19 (DARE-19): a randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet Diabetes & Endocrinology. 2021.
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