Abstract #1001507: A Case of Ketoacidosis with Complex Acid-Base Disturbances in a Patient with Type 2 Diabetes Mellitus, Pregnancy, and COVID-19

Abstract

1001503 Safety And Efficacy of Empagliflozin in Pakistani Muslim Patients with Type 2 Diabetes (SAFE-PAK) Author Block: Azizul H. Aamir, MBBS (PAK), MRCP (UK), FRCP (Edin), FACE(US) presenter and primary author, Hayatabad Medical Complex; Umar Y. Raja, FCPS co-author, Shifa International Hospital; Ali Asghar, FCPS co-author, Fatimiyah Hospital; Saeed A. Mahar, FCPS co-author, National Institute of Cardiovascular Disease; tahir Ghaffar, FCPS co-author, Hayatabad Medical Complex; Ibrar Ahmed, FCPS co-author, Lady Reading Hospital; Faisal M. Qureshi, FCPS co-author, Al-Khaliq Hospital; Jamal Zafar, FCPS co-author, Hanif Medical Center; Imtiaz Hassan, FCPS co-author, Diabetes Institute of Pakistan; Amna Riaz, FCPS co-author, Jinnah Hospital; Irshad khoso, FCPS co-author, Balochistan Medical Center; Jahanzeb K. khan, MBBS co-author, Dow University of Health Sciences; Mahwish Raza, MsPH coauthor, Shaheed Zulfikar Ali Bhutto Institute of Science And Technology; Jaffer B. Baqar, MSc (Statistics) co-author, University of Karachi; Abbas Raza, DBIM co-author, National Defence Center Objective: Glycosuria increases the risk of genitourinary infections in diabetes. To establish the safety and efficacy of empagliflozin versus usual care in Pakistani Muslim diabetic patients having wet personal hygiene practices. Methods: A multicenter randomised clinical trial conducted in five cities across Pakistan from July-19 to August-20. Twelve participating centers screened 745 patients and of these 244 (32.7%) were enrolled. Both gender aged 18-75 years, Body Mass Index 45kg/m2, HbA1c 7%-10% and treatment naïve to empagliflozin were included. Exclusion criteria included estimated glomerular filtration rate < 45mL/min/1.73m2, positive urine culture, presence of serum ketones, and impaired liver functions. Treatment allocation was done through randomization; G-1: empagliflozin over and above standard care and G-2: standard care group (without empagliflozin). Patients were followed-up for 24 weeks. Results: Out of 244, total 129 (52.7%) were randomized to G-1. All baseline demographics and laboratory investigations were comparable with p-value >0.05. Hypoglycemic events were significantly more in G-2 (G-1:12.9% vs G-2:17.8%; p1⁄40.041) whereas positive urine culture (G-1:7.4% vs G-2: 9.9%; p1⁄40.521), fungal infection (G-1:0 vs G-2:2%; p1⁄40.522), dehydration (G-1:3.7% vs 3.9%; p1⁄40.923) and hypotension (G-1:0.9% vs 2.9%; p1⁄40.281) were insignificant. The 6 months mean HbA1c reduction was significant in both groups; [G-1:0.91±0.2; p< 0.001 vs G2:0.8±0.1; p< 0.001]. The mean reduction of weight [G-1:1.4±0.4; p1⁄40.002 vs G-2:0.01±0.5; p1⁄40.999] and systolic blood pressure [G-1:9.5±3.3; p1⁄40.025 vs G-2:7.6±3.5; p1⁄40.120] were significant in G-1. Discussion/Conclusion: Empagliflozin showed better safety profile as compared to standard care group and achieved better glycemic control without weight gain and no additional risk of genitourinary infections in muslim diabetic patients. https://doi.org/10.1016/j.eprac.2021.04.555 S40 Abstract #1001507 A Case of Ketoacidosis with Complex Acid-Base Disturbances in a Patient with Type 2 Diabetes Mellitus, Pregnancy, and COVID-19 Author Block: Samridhi Syal, MBBS Primary author, Department of Medicine, Houston Methodist Hospital; Jessica Lucier, MD Coauthor, Division of Endocrinology and Bone Metabolism, Department of Medicine, Houston Methodist Hospital; Anish Bhakta, DO Co-author, Division of Nephrology, Department of Medicine, Houston Methodist Hospital; Horacio E. Adrogue, MD, FASN Co-author, Division of Nephrology, Department of Medicine, Houston Methodist Hospital; Archana R. Sadhu, MD, FACE Co-author, Division of Endocrinology and Bone metabolism, Department of Medicine, Houston Methodist Hospital Introduction: Pregnancy, diabetes, and COVID-19 are each associated with ketosis/ketoacidosis and changes in acid-base status. We present our approach to a case of complex acid-base disturbances in the presence of all three conditions. Case Description: A 27-year-old female with type 2 diabetes and 31 weeks gestation presented with shortness of breath and COVID-19 pneumonia. She was tachypneic and required oxygen (3L/min) via nasal cannula on presentation. Laboratory evaluation on day 0 showed bicarbonate (CO2) 14 mEq/L and a corrected anion gap (AG) 21 mEq/L consistent with high and normal anion gap metabolic acidosis (arterial blood gas and ketones were not available). A1C was 7.5% and glucose 226 mg/ dL. Home insulin regimen was resumed on admission. She received convalescent plasma and remdesivir for COVID-19 along with beclomethasone for fetal lung maturity. However, on day 2 the patient decompensated with worsening tachypnea and acidosis. She was now found to have acidemia (pH 7.32) with metabolic acidosis (CO2 9 mEq/L, AG 23 mEq/L) and appropriately compensated respiratory alkalosis (pCO2 22 mmHg). Further workup showed a combination of normal and high AG metabolic acidosis in addition to hyperglycemia (239 mg/dL), ketonuria, and elevated beta hydroxybutyrate level (2.83 mmol/ L). A component of diabetic ketoacidosis (DKA) was suspected. Treatment with DKA protocol resolved the acidemia (pH 7.42) and normalized the AG (15 mEq/L) on day 3. However, metabolic acidosis (CO2 14 mEq/L) and respiratory alkalosis (pCO2 24mmHg) persisted. She was also treated with systemic corticosteroids for COVID-19 and did not require intubation. Prenatal non-stress testing was consistent with a low risk of fetal complications and daily fetal monitoring was stable. The patient was transitioned to a subcutaneous insulin regimen and discharged home on day 7. At 37 weeks gestation, an elective cesarean section was performed without complications. Neonatal hypoglycemia was noted in an otherwise healthy infant requiring 48hour monitoring before discharge. Discussion: COVID-19 has been associated with ketosis and ketoacidosis in patients with and without diabetes. It is postulated that SARS-CoV-2 virus can damage pancreatic islets resulting in insulin deficiency. Pregnancy itself is associated with respiratory alkalosis with incompletely compensated metabolic acidosis due to hormonal changes. Also, pregnancy is a state of insulin resistance predisposing to ketoacidosis; however, the occurrence of DKA in pregnancy is generally rare. Our patient had complex acid-base changes consisting of metabolic acidosis (high & normal AG) and appropriately compensated respiratory alkalosis. We concluded that high AG metabolic acidosis was likely from ketoacidosis (diabetes, COVID-19, and/or pregnancy) Diabetes/Prediabetes/Hypoglycemia Endocrine Practice 27 (2021) S24eS71 and normal AG acidosis was compensatory from respiratory alkalosis (COVID-19 and pregnancy). After treatment with DKA protocol, pregnancy-related respiratory alkalosis and metabolic acidosis persisted. This complex case required a detailed analysis of the many etiologies of acid-base disturbances for appropriate management. https://doi.org/10.1016/j.eprac.2021.04.556