A case of "pseudo-ketoacidosis".

Sir,

A-29-year old known case of type 2 diabetes mellitus (T2DM) since the past 2 years, who is presently living in the US and was on a visit to India, got himself evaluated for his glycemic status, due to polyuria. In addition to his HbA1C and blood glucose levels, he also had a complete urine examination done. HbA1c was 6.7%, fasting blood glucose was 120 mg/dL and the complete urine examination demonstrated 3+ glycosuria and 2+ ketonuria. Diabetic ketoacidosis was diagnosed and he was advised admission. However, the patient was asymptomatic. Hence he went in for a second opinion. When he was questioned closely, he admitted that he was on a religious fast since morning. He was on treatment with metformin and canagliflozin and had taken his morning dose of medication as usual, in spite of the fast. The heavy renal glycosuria caused by canagliflozin[1] coupled with the ketonuria due to his fasting had contributed to a surreal picture of ketoacidosis for which the patient could have been unnecessarily hospitalized, if the relevant facts had not been brought out.

Canagliflozin is an sodium-glucose transport protein 2 (SGLT-2) inhibitor that acts by preventing the renal reabsorption of glucose in urine.[23] It is presently approved by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA), and is presently marketed both in Europe and the USA.[4] It will also shortly be introduced into the Indian market. Experience of most Indian physicians with this drug is limited. Noteworthy, in spite of many recommendations to the contrary, a majority of Indian labs still continue to measure and report urine sugars. Ritual fasting is also a common occurrence in India. Further, while the recent Ramzan guidelines have not included Canagliflozin in the list of suitable medications, given its very low potential to cause hypoglycaemia, it is very likely that it will soon be integral to the management of diabetic patients for numerous indications, including religious fasts.[5] In such a setting, these episodes of pseudo-ketoacidosis would become much more common. This report highlights the importance of reviewing diabetic medications in special situations like religious fasting and also whenever biochemical reports are in dissonance with the clinical picture. Also, routine testing for urine sugars is an investigation which is best relegated to the sands of time and active efforts should be made to ensure that this change is brought about.