Diabetic Ketoacidosis in a Type 2 Diabetes Patient After Initiation of Over-the-Counter Weight Loss Medications: A Cautionary Tale

Case Presentation

A 50-year-old Caucasian man with a history of obesity and type 2 diabetes presented to the emergency room with a 2-day history of blurry vision and severe polyuria and polydipsia. He was found to have diabetic ketoacidosis (DKA) and was admitted to the hospital for further management; endocrinology service was subsequently consulted. Review of his chart showed that he had been diagnosed with type 2 diabetes about 2 years before this admission when at an annual screening his A1C was 6.6% (49 mmol/mol). Metformin monotherapy was then started; however, he quickly stopped the medication because of gastrointestinal upset. He further improved his diet and increased his physical activity and, about 6 months before his admission with DKA, his primary care provider had changed his follow-up visits to once per year because his A1C was 6.1% (43 mmol/mol), his blood pressure was 130/78 mmHg, random LDL cholesterol was 115 mg/dL, and triglycerides were 304 mg/dL. No medications were prescribed.

At the time of his admission with hyperglycemic emergency, the diagnosis of DKA was made based on a serum glucose level of 621 mg/dL, bicarbonate of 20 mEq/L (normal range 22–32), anion gap of 19, and presence of serum ketones. The DKA episode was resolved 10 hours after admission to the intensive care unit (ICU) for intravenous fluid resuscitation and insulin therapy.

During initial inpatient evaluation, we found no signs or symptoms supporting concurrent infection or pancreatitis; he was hemodynamically stable and had a BMI of 32 kg/m², with a weight of 85 kg. His A1C was 12.8% (116 mmol/mol), triglycerides were 7,783 mg/dL, and total cholesterol was 411 mg/dL; thyroid-stimulating hormone and liver function tests were within normal limits.

As he was transferred from ICU to the floor to receive basal-bolus insulin therapy, further history was obtained from the …