(1446) Confronting Postoperative Challenges: Diabetes Medications and Complications

Introduction: Patients with diabetes are at greater likelihood of requiring surgery and developing postoperative complications. With the advent of new therapies, it is crucial to review the safety of anti-hyperglycemic agents in the perioperative period to decrease the risk of adverse effects. Here, we present a case of a 53-year-old man who, during the postoperative period, developed severe acidosis as a result of a combination of Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), Sodium-glucose cotransporter-2 (SGLT2) inhibitors, and biguanides—culminating in euglycemic diabetic ketoacidosis (DKA) and metformin-associated lactic acidosis (MALA).

Description: A 53-year-old male patient with a history of diabetes mellitus was admitted to the hospital for elective right knee arthroplasty. On the first day after surgery, the patient developed abdominal pain, intractable nausea, and emesis. Laboratory tests revealed hyperkalemia of 6.5 mmol/L, serum bicarbonate 15 mmol/L, BUN 68 mg/dL, serum creatinine 8.74 mg/dL, glucose 84 mg/dL, anion gap 32, lactate 21 mmol/L, beta-hydroxybutyrate level > 7 mmol/L, and venous pH 6.98. Medical reconciliation demonstrated that the patient was initiated on the maximum dose of Semaglutide 2 mg one week prior, which led to decreased appetite, nausea, and emesis. He continued Dapagliflozin, with the last dose taken one day before surgery, and continued with home Metformin. There was a concern for euglycemic DKA given Dapagliflozin use and MALA. The patient was started on insulin infusion and bicarbonate therapy and was subsequently initiated on continuous renal replacement therapy (CRRT) given inadequate response. The patient showed significant improvement, and CRRT was discontinued within 48 hours, with resolution of acidosis and recovery of renal function in the subsequent days.

Discussion: Metformin-associated lactic acidosis can occur following acute overdose or in patients with kidney impairment. Mortality in MALA can be as high as 36 percent, with increased mortality seen in those with lower serum pH and higher serum lactate concentrations, often necessitating hemodialysis. With the advent of newer oral and injectable anti-hyperglycemic agents, concomitant euglycemic DKA and MALA put patients at higher risk of mortality, especially in the perioperative period.