Low BMI a novel factor in SGLT2i ketoacidosis: Australian study

Wednesday, 3 Nov 2021

Extra vigilance is warranted at colonoscopy for SGLT2 inhibitor‐associated diabetic ketoacidosis in people with low body mass index (BMI), according to an Australian study.

The cross sectional study, conducted at four tertiary hospitals in Melbourne between June and December 2020, compared capillary glucose and ketone concentrations in 358 people on the day of colonoscopy.

The study, published in Clinical Endocrinology, allocated patients to one of four groups – type 2 diabetes that was SGLT2i‐treated, diabetes not treated by SGLT2i, impaired fasting glycaemia or normoglycaemia.

“Ketone concentrations differed significantly between groups (p = .001), with lower levels in participants with IFG than in normoglycaemic participants and those taking SGLT2i,” the study said.

In SGLT2i‐treated participants and in the entire cohort, lower BMI values were associated with higher ketone levels.

“All three SGLT2i‐treated participants with ketone concentrations above the upper limit of the normoglycaemic reference range of 1.7 mmol/L had BMI < 25 kg/m2.”

“In a multiple regression analysis of SGLT2i‐treated participants, lower BMI was the only variable independently associated with ketone concentrations.”

Across the entire cohort, BMI, age and fasting glucose were independently associated with ketones.

The study found no correlation between HbA1c and capillary ketone concentrations in SGLT2i‐treated or non‐ SGLT2i‐treated participants, or for the combined diabetes groups.

The study said that despite guidelines to withhold SGLT2i, 31 participants nevertheless took them within 72 hours of their procedure resulting in marked variability in ketone concentrations from 0.1 to 2.4 mmol/L.

The investigators said their key finding – that lower BMI was independently associated with higher ketone concentrations in the SGLT2i group and the entire study cohort – was novel and interesting.

“Through incompletely understood mechanisms, hyperinsulinaemia suppresses ketogenesis in obese individuals and possibly contributes to lower ketones compared to lean controls.”

“Similarly, in the diabetes groups, higher ketone concentrations may relate to lower C‐peptide and insulin concentrations observed in people with type 2 diabetes who have lower BMI compared to those with higher BMI.”

They noted that although the specific type of bowel prep was not associated with ketone concentrations, the overall role of the different preparations in promoting ketosis is not known, nor is the time‐course of ketone production before and after the procedure.

“Pending larger, confirmatory studies, people undergoing colonoscopy with SGLT2i‐treated diabetes warrant clinical vigilance if they have a lower BMI, as they may be at increased risk for DKA,” they concluded.


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