Periprocedural Euglycemic Diabetic Ketoacidosis Associated With Sodium–Glucose Cotransporter 2 Inhibitor Therapy During Colonoscopy

More than 10% of adults undergoing colonoscopy have type 2 diabetes (T2D) (1). The use of sodium–glucose cotransporter 2 inhibitors (SGLT2i) has increased due to their glycemic control and benefits of lowering cardiovascular morbidity and mortality as well as reducing diabetic nephropathy (2,3).Diabetic ketoacidosis (DKA) is a rare complication associated with SGLT2i. Precipitating factors include fasting, dietary modifications, intercurrent illnesses, surgical stress, insulin insufficiency, and inappropriate management of SGLT2i in the periprocedural period. SGLT2i-induced ketoacidosis can present either with elevated blood glucose levels (BGL) or with near-normal BGL (<250 mg/dL), termed euglycemic diabetic ketoacidosis (EDKA) (4). Interventional gastroenterology procedures, in particular colonoscopy, pose risk for EDKA with SGLT2i use due to cathartic bowel preparation, fluid-only dietary restriction, and fasting. We present a series of cases of EDKA in the setting of colonoscopy and discuss its procedure-specific implications.Eight cases of SGLT2i-associated EDKA in the setting of colonoscopy were identified between August 2019 and February 2020 across three centers. Five cases were identified through the Central Adelaide Local Health Network (CALHN), South Australia, and three were identified at the Royal Brisbane and Women’s Hospital (RBWH), Queensland. Ethical approval was obtained from the CALHN (13194) and RBWH (LNR/2020/QRBW/61873) Human Research Ethics Committees.All patients had T2D and were aged between 45 and 75 years (Table 1). One patient was on a very-low-calorie diet, which may have been a contributory …