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Why Is Dka Rare In Type 2 Diabetes

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. See also the separate Childhood Ketoacidosis article. Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and ketonaemia:[1] Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks). Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA). Bicarbonate below 15 mmol/L and/or venous pH less than 7.3. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA.[2] Epidemiology DKA is normally seen in people with type 1 diabetes. Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes. In the UK nearly 4% of people with type 1 diabetes experience DKA each year. About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes. About 8% of episodes occur in hospital patients who did not primarily present with DKA.[2] However, DKA may also occur in people with type 2 diabetes, although people with type 2 diabetes are much more likely to have a hyperosmolar hyperglycaemic state. Ketosis-prone type 2 diabetes tends to be more common in older, overweight, non-white people with type 2 diabetes, and DKA may be their Continue reading >>

Severe Diabetic Ketoacidosis In A Newly Diagnosed Child With Type 2 Diabetes Mellitus: A Case Report

Severe Diabetic Ketoacidosis In A Newly Diagnosed Child With Type 2 Diabetes Mellitus: A Case Report

Abdulmoein E Al-Agha1* and Mohammed A Al-Agha2 1Department of Pediatric Endocrinology, King Abdul-Aziz University Hospital, Saudi Arabia 2Faculty of Medicine, King Abdul-Aziz University, Saudi Arabia Citation: Abdulmoein E Al-Agha1, Mohammed A Al-Agha (2017) Severe Diabetic ketoacidosis in a Newly Diagnosed Child with Type 2 Diabetes Mellitus: A Case Report. J Diabetes Metab 8:724. doi:10.4172/2155-6156.1000724 Copyright: © 2017 Al-Agha AE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Visit for more related articles at Journal of Diabetes & Metabolism Abstract Background: Diabetes ketoacidosis (DKA) is an acute complication of both type 1 and type 2 diabetes mellitus (DM). DKA is characterized by the presence of hyperglycemia, ketosis, ketonuria, and metabolic acidosis. Cerebral edema is a rare but rather a serious complication of DKA. Case presentation: An obese 12-year-old, Egyptian boy, previously medically free, presented to the emergency room (ER) of King Abdulaziz university hospital, with two weeks' histories of dizziness, shortness of breath, polyuria, polydipsia & nocturia. His symptoms were deteriorating with a change in sensorial and cognitive functions at the time of presentation. He was diagnosed with type 2 DM based upon clinical background, namely the presence of obesity (weight+7.57 Standard Deviation Score (SDS), height+1.4 SDS, and body mass index (BMI) of 34.77 kg/m2 (+3.97SDS) together with the presence of Acanthosis nigricans and biochemically based on, normal level of serum insulin, normal serum level of connecting peptide and negative autoantibodies. H Continue reading >>

The Occurrence Of Diabetic Ketoacidosis In

The Occurrence Of Diabetic Ketoacidosis In

Type 2 Diabetic Adults Chih-Hsun Chu; Jenn-Kuen Lee; Hing-Chung Lam; Chih-Chen Lu Division of Endocrinology and Metabolism, Department of Medicine, Veterans General Hospital-Kaohsiung, School of Medicine, National Yang-Ming University, Taipei, Taiwan. Running title: The Occurrence of Diabetic Ketoacidosis in Type 2 Diabetic Adults Abstract OBJECTIVE. To study the diabetic ketoacidosis (DKA) episodes which occurred in the type 2 diabetic adults. STUDY DESIGN. We reviewed retrospectively the charts of patients who were admitted to the division of endocrinology and metabolism from Jan. 1991 to Dec. 1997 due to DKA. RESULTS. Total 121 adult patients with 137 episodes (57 females and 80 males) of DKA, with mean age of 45.90 years. 98 episodes (71.5%) occurred in type 2 diabetes mellitus (DM) with mean age of 48.73, which was significantly older than type 1 diabetic patients. Among ten patients suffered from repeated episodes of DKA, 2 four patients belonged to type 2 DM. 33 episodes (24.1%) occurred in patients without a history of DM, however, up to 24 episodes were classified as in type 2. Infection was the most important precipitating factor in type 2 diabetic patients, with respiratory tract and urinary tract accounting for the two most common foci. In type 1 diabetic patients, poor drug compliance accounted for the leading one. Twelve patients (one in type 1 DM and eleven in type 2 DM) expired, giving the mortality rate of 8.8%. Only old age contributed to fatality in type 2 diabetic patients. Type 2 diabetic patients had lower value of serum potassium and the occurrence of hyperkalemia was less than that of type 1. CONCLUSION. Owing to high percentage of adult DKA episodes occurred in type 2 DM, more attention should be pay to these patients. KEYWORDS: diabetes mellitu Continue reading >>

Ketosis-prone Type 2 Diabetes

Ketosis-prone Type 2 Diabetes

Time to revise the classification of diabetes Diabetic ketoacidosis (DKA) is the most serious hyperglycemic emergency in patients with diabetes. DKA is reported to be responsible for >100,000 hospital admissions per year in the U.S. (1) and is present in 25–40% of children and adolescents with newly diagnosed diabetes (2) and in 4–9% of all hospital discharge summaries among adult patients with diabetes (3,4). DKA has long been considered a key clinical feature of type 1 diabetes, an autoimmune disorder characterized by severe and irreversible insulin deficiency. In recent years, however, an increasing number of ketoacidosis cases without precipitating cause have also been reported in children, adolescents, and adult subjects with type 2 diabetes (5–7). These subjects are usually obese and have a strong family history of diabetes and a low prevalence of autoimmune markers. At presentation, they have impairment of both insulin secretion and insulin action, but aggressive diabetes management results in significant improvement in β-cell function and insulin sensitivity sufficient to allow discontinuation of insulin therapy within a few months of treatment (7–9). Upon discontinuation of insulin, the period of near-normoglycemic remission may last for a few months to several years (10–13). This clinical presentation has been reported primarily in Africans and African Americans (6,7,14–16) and also in other minority ethnic groups (12,17,18). This variant of type 2 diabetes has been referred to in the literature as idiopathic type 1 diabetes, atypical diabetes, Flatbush diabetes, diabetes type 1 (1/2) (somewhere between type 1 and type 2 diabetes), and more recently as ketosis-prone type 2 diabetes (9). In this issue of Diabetes Care, Balasubramayam et al. (19) co Continue reading >>

What Is Diabetic Ketoacidosis?

What Is Diabetic Ketoacidosis?

Having diabetes means that there is too much sugar (glucose) in your blood. When you eat food, your body breaks down much of the food into glucose. Your blood carries the glucose to the cells of your body. An organ in your upper belly, called the pancreas, makes and releases a hormone called insulin when it detects glucose. Your body uses insulin to help move the glucose from the bloodstream into the cells for energy. When your body does not make insulin (type 1 diabetes), or has trouble using insulin (type 2 diabetes), glucose cannot get into your cells. The glucose level in your blood goes up. Too much glucose in your blood (also called hyperglycemia or high blood sugar) can cause many problems. People with type 1 diabetes are at risk for a problem called diabetic ketoacidosis (DKA). It is very rare in people with type 2 diabetes. DKA happens when your body does not have enough insulin to move glucose into your cells, and your body begins to burn fat for energy. The burning of fats causes a build-up of dangerous levels of ketones in the blood. At the same time, sugar also builds up in the blood. DKA is an emergency that must be treated right away. If it is not treated right away, it can cause coma or death. What can I expect in the hospital? You will need to stay in the hospital in order to bring your blood sugar level under control and treat the cause of the DKA. Several things may be done while you are in the hospital to monitor, test, and treat your condition. They include: Monitoring You will be checked often by the hospital staff. You may have fingersticks to check your blood sugar regularly. This may be done as often as every hour. You will learn how to check your blood sugar level in order to manage your diabetes when you go home. A heart (cardiac) monitor may Continue reading >>

A Rare Presentation Of Type 2 Diabetes: Diabetic Ketoacidosis, Acute Pancreatitis, And Hypertriglyceridaemia

A Rare Presentation Of Type 2 Diabetes: Diabetic Ketoacidosis, Acute Pancreatitis, And Hypertriglyceridaemia

Introduction: The triad of diabetic ketoacidosis (DKA), acute pancreatitis (AP), and hypertriglyceridaemia (HTG) has been described mainly in T1DM with few cases in T2DM. We report the first case of this triad revealing T2DM. Case report: A 30-year-old male with strong family history of T2DM presented to the emergency with severe epigastric pain radiating to the back associated with abdominal swelling, vomiting and diarrhea. He also reported history of polyuria and polydipsia with undocumented weight loss for one month prior to presentation. Clinically, he was found to have distended abdomen which was tender all over especially in the epigastrium. A urine dipstick was positive for +3 ketone and +3 glucose. The serum glucose level was 30.6 mmol/l. Blood work demonstrated high anion gap metabolic acidosis, high amylase and moderate hypertriglyceridaemia (10.67 mmol/l). A CT scan of the abdomen revealed that the pancreas was bulky with peri-pancreatic fluid collection suggestive of acute mild exudative pancreatitis. The diagnosis of DKA, AP precipitated by HTG was established. The patient was managed with intravenous fluid, potassium replacement, and insulin infusion in addition to analgesic until he improved. He was then shifted to multiple doses of insulin and started on fenofibrate 145 mg daily. The C-peptide was 538 pmol/l (366–1466). The HbA1c was 10%, and all pancreatic auto-antibodies were negative. At the follow up visit two weeks later, the patient was doing well. His home glucose monitoring showed fasting blood sugar ranging between 4.4 and 6.5 mmol/l and 2 h postprandial readings between 8 and 10 mmol/l. The triglyceride level becomes normal (1.72 mmol/l). Conclusion: This patient is likely suffering from T2DM supported by detectable C-peptide level and negati Continue reading >>

What You Should Know About Diabetic Ketoacidosis

What You Should Know About Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a buildup of acids in your blood. It can happen when your blood sugar is too high for too long. It could be life-threatening, but it usually takes many hours to become that serious. You can treat it and prevent it, too. It usually happens because your body doesn't have enough insulin. Your cells can't use the sugar in your blood for energy, so they use fat for fuel instead. Burning fat makes acids called ketones and, if the process goes on for a while, they could build up in your blood. That excess can change the chemical balance of your blood and throw off your entire system. People with type 1 diabetes are at risk for ketoacidosis, since their bodies don't make any insulin. Your ketones can also go up when you miss a meal, you're sick or stressed, or you have an insulin reaction. DKA can happen to people with type 2 diabetes, but it's rare. If you have type 2, especially when you're older, you're more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). It can lead to severe dehydration. Test your ketones when your blood sugar is over 240 mg/dL or you have symptoms of high blood sugar, such as dry mouth, feeling really thirsty, or peeing a lot. You can check your levels with a urine test strip. Some glucose meters measure ketones, too. Try to bring your blood sugar down, and check your ketones again in 30 minutes. Call your doctor or go to the emergency room right away if that doesn't work, if you have any of the symptoms below and your ketones aren't normal, or if you have more than one symptom. You've been throwing up for more than 2 hours. You feel queasy or your belly hurts. Your breath smells fruity. You're tired, confused, or woozy. You're having a hard time breathing. Continue reading >>

Diabetes - Type 2

Diabetes - Type 2

An in-depth report on the causes, diagnosis, treatment, and prevention of type 2 diabetes. Highlights DIABETES STATISTICS According to the U.S. Centers for Disease Control and Prevention's (CDC) 2014 National Diabetes Fact Sheet, more than 29 million American adults and children have diabetes. 86 million Americans aged 20 years and older have pre-diabetes, a condition that increases the risk for developing diabetes. About 1 in 4 Americans that have diabetes do not know that they have this disease. Diabetes rates are increasing among both adults and children. In 2010, 26 million Americans had diabetes and 79 million had prediabetes. TYPE 2 DIABETES RISK FACTORS Risk factors for type 2 diabetes and pre-diabetes include: A previous diabetes test showing impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) Age 45 years or older Family history of diabetes Being overweight (BMI 25-30) or obese (BMI>30) Inactive lifestyle and lack of regular exercise African-American, Hispanic/Latin American, American Indian and Alaska Native, Asian-American, or Pacific Islander ethnicity High blood pressure (140/90 mm Hg or higher) Low HDL (good) cholesterol and high triglycerides History of gestational diabetes (diabetes during pregnancy) NUTRITION GUIDELINES Key recommendations from the American Diabetes Association (ADA) nutritional guidelines include: Your eating plan should be individualized to accommodate your unique health profile. For nutritional advice, consult a dietitian or participate in a diabetes self-management education program. The ADA no longer has general recommendations for the percentage of daily calories that carbohydrates, fats, or protein should comprise. Those percentages need to be individually determined for each person. There is no evidence that any s Continue reading >>

Ketosis-prone Type 2 Diabetes

Ketosis-prone Type 2 Diabetes

Background The original schema for classifying diabetes mellitus (DM) consisted of 2 categories known as type 1 diabetes mellitus and type 2 diabetes mellitus. Type 1 diabetes was also known as insulin-dependent diabetes. Patients with this type of diabetes were considered prone to develop diabetic ketoacidosis (DKA). Patients with type 1 diabetes were found to have an absolute insulin deficiency due to autoimmune destruction of pancreatic beta cells. Patients with type 2 diabetics, or noninsulin-dependent diabetes, were not considered to be at risk for DKA. Type 2 diabetes is strongly associated with obesity and a family history of diabetes. These patients have peripheral insulin resistance with initially normal or elevated circulating levels of endogenous insulin. Practice Essentials Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. See the image below. See Clinical Findings in Diabetes Mellitus, a Critical Images slideshow, to help identify various cutaneous, ophthalmologic, vascular, and neurologic manifestations of DM. Signs and symptoms Many patients with type 2 diabetes are asymptomatic. Clinical manifestations include the following: See Presentation for more detail. Diagnosis Diagnostic criteria by the American Diabetes Association (ADA) include the following [1] : Whether a hemoglobin A1c (HbA1c) level of 6.5% or higher should be a primary diagnostic criterion or an optional criterion remains a point of controversy. Indications for diabetes screening in asymptomatic adults includes the following [2, 3] : Overweight and 1 or more other risk factors for diabetes (eg, first-d Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus.[1] Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness.[1] A person's breath may develop a specific smell.[1] Onset of symptoms is usually rapid.[1] In some cases people may not realize they previously had diabetes.[1] DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances.[1] Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids.[1] DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies.[3] DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine.[1] The primary treatment of DKA is with intravenous fluids and insulin.[1] Depending on the severity, insulin may be given intravenously or by injection under the skin.[3] Usually potassium is also needed to prevent the development of low blood potassium.[1] Throughout treatment blood sugar and potassium levels should be regularly checked.[1] Antibiotics may be required in those with an underlying infection.[6] In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended.[1][6] Rates of DKA vary around the world.[5] In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% a year.[1][5] DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost univ Continue reading >>

Diabetes - Type 2

Diabetes - Type 2

Description An in-depth report on the causes, diagnosis, treatment, and prevention of type 2 diabetes. Alternative Names Type 2 diabetes; Maturity onset diabetes; Noninsulin-dependent diabetes Highlights Diabetes Statistics According to the U.S. Centers for Disease Control and Prevention’s (CDC) National Diabetes Fact Sheet, nearly 26 million American adults and children have diabetes. About 79 million Americans aged 20 years and older have pre-diabetes, a condition that increases the risk for developing diabetes. Diabetes and Cancer Type 2 diabetes increases the risk for certain types of cancer, according to a consensus report from the American Diabetes Association and the American Cancer Society. Diabetes doubles the risk for developing liver, pancreatic, or endometrial cancer. Certain medications used for treating type 2 diabetes may possibly increase the risk for some types of cancers. Screening for Gestational Diabetes Mellitus The American Diabetes Association recommends that pregnant women without known risk factors for diabetes get screened for gestational diabetes at 24 - 28 weeks of pregnancy. Pregnant women with risk factors for diabetes should be screened for type 2 diabetes at the first prenatal visit. Aspirin for Heart Disease Prevention The American Diabetes Association now recommends daily low-dose (75 - 162 mg) aspirin for men older than age 50 and women older than age 60 who have diabetes and at least one additional heart disease risk factor (such as smoking, high blood pressure, high cholesterol, family history, or albuminuria). Guidelines for Treatment of Diabetic Neuropathy The anticonvulsant drug pregabalin (Lyrica) is a first-line treatment for painful diabetic neuropathy, according to recent guidelines released by the American Academy of Neurol Continue reading >>

Incidence Of Diabetic Ketoacidosis Among Patients With Type 2 Diabetes Mellitus Treated With Sglt2 Inhibitors And Other Antihyperglycemic Agents

Incidence Of Diabetic Ketoacidosis Among Patients With Type 2 Diabetes Mellitus Treated With Sglt2 Inhibitors And Other Antihyperglycemic Agents

Jump to Section 1. Introduction Diabetic ketoacidosis (DKA) is a serious, acute metabolic complication of diabetes characterized by absolute or relative insulin deficiency [[1], [2]], with an overall mortality rate of up to 5% in experienced healthcare centers [3]. Insulin deficiency, increased insulin counter-regulatory hormones (cortisol, glucagon, growth hormone, and catecholamines) and peripheral insulin resistance lead to hyperglycemia, dehydration, ketosis, and electrolyte imbalance, which underlie the pathophysiology of DKA [2]. While DKA is a commonly recognized vulnerability in autoimmune diabetes, stressful conditions such as trauma, surgery, or infection also increase DKA risk in patients with type 2 diabetes mellitus [4]. In fact, studies have reported that patients with type 2 diabetes accounted for 12–56% of the DKA cases, had longer hospital stays, and higher mortality (which possibly was due to advanced age and comorbidities) than patients with type 1 diabetes [[3], [5]]. Sodium glucose co-transporter 2 inhibitors (SGLT2i’s) are a new class of oral antihyperglycemic agents (AHA) that lower blood glucose through an insulin-independent mechanism, by suppressing renal glucose reabsorption and increasing urinary glucose excretion [6]. Currently, 3 SGLT2i’s have been approved in the US and Europe for the treatment of type 2diabetes: canagliflozin, dapagliflozin, and empagliflozin (initial approval March 29, 2013, January 8, 2014, August 1, 2014 in the US, November 15, 2013, November 12, 2012, May 22, 2014 in Europe, respectively). By mid-2015, based on spontaneous adverse event reports, the US Food and Drug Administration and the European Medicines Agency [7] had both issued statements that medicines in the SGLT2i class of drugs may be associated with a Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>

Forms Of Diabetes

Forms Of Diabetes

Type 1 diabetes accounts for roughly 10% of the diabetes cases in the world with the majority being Type 2. An estimated 1-5% of all diagnosed cases of diabetes are rare types, such as latent autoimmune diabetes in adults (LADA), maturity onset diabetes in the young (MODY), cystic fibrosis related diabetes (CFRD), Cushing’s syndrome and others. Explore these various forms of diabetes and what makes them distinct in the diabetes family. Learn how to test for diabetes type. What is Type 1 Diabetes? Type 1 diabetes is a chronic, autoimmune condition that occurs when the body’s own immune system attacks the insulin-producing beta cells of the pancreas. This attack leaves the pancreas with little or no ability to produce insulin, a hormone that regulates blood sugar. Without insulin, sugar stays in the blood and can cause serious damage to organ systems, causing people to experience Diabetic ketoacidosis (DKA).READ MORE What is Type 2 Diabetes? Type 2 diabetes occurs when the body cannot properly use insulin, a hormone that regulates blood sugar. This is also known as insulin resistance. In Type 2, the pancreas initially produces extra insulin, but eventually cannot keep up with production in order to keep blood sugar levels in check. Of the 415 million diabetes cases globally, 90% are estimated to be Type 2.READ MORE Gestational diabetes mellitus (GDM) is a form of diabetes that affects pregnant women, and occurs in 1 in 25 pregnancies worldwide. It is caused by the malfunctioning of insulin receptors, due to the presence of hormones from the placenta. It develops usually around the 24th week of pregnancy and will continue to affect both the mother and unborn child throughout the pregnancy.READ MORE LADA, (Latent Autoimmune Diabetes in Adults) diabetes is rare and known Continue reading >>

Diabetic Ketoacidosis In A Patient With Type 2 Diabetes On Canagliflozin And Dexamethasone

Diabetic Ketoacidosis In A Patient With Type 2 Diabetes On Canagliflozin And Dexamethasone

An 87-year-old Chinese male with type 2 diabetes presented to the emergency department with generalized weakness, lethargy, and anorexia for several days. His past medical history included resection of a frontal meningioma 10 days prior (discharged postoperative day 2), previous frontal meningioma resection in 2009, hypertension, hyperlipidemia, atrial fibrillation, and benign prostatic hypertrophy. His diabetes was diagnosed 7 years earlier, his hemoglobin A1c 20 days prior to admission was 6.5% (48 mmol/mol), and his body mass index was 22.5 kg/m2. He was not performing home glucose monitoring, and his blood glucose was not monitored with point-of-care testing during his surgical admission. He had stage 3 chronic kidney disease (estimated glomerular filtration rate, 53 mL/min; baseline creatinine, 89 μmol/L) but no retinopathy or neuropathy, and he had never required hospitalization for hyperglycemia. At presentation, his medications included: dexamethasone 2 mg orally twice a day (tapering dose, discharged on 4 mg three times a day), canagliflozin 100 mg orally daily (started 8 weeks prior), metformin 500 mg orally twice a day, sitagliptin 50 mg orally twice a day, doxazosin 4 mg orally nightly, finasteride 5 mg orally daily, niacin extended release 500 mg orally twice a day, rosuvastatin 5 mg orally daily, and acetylsalicylic acid 81 mg orally daily. He had previously been taking hydrochlorothiazide 12.5 mg orally daily and olmesartan 20 mg orally daily, but these medications were stopped 6 weeks prior to his surgery because of hypotension. At presentation, he denied any neurologic or infectious symptoms. On physical examination, he appeared lethargic and unwell. His vital signs were: heart rate 152 beats/minute, blood pressure 76/53 mm Hg, respiratory rate 28 brea Continue reading >>

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