Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor

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Abbas" }, { "@type": "Person", "name": "Fajr Jamal A.bagi" }, { "@type": "Person", "name": "Asmaa Abdalkarim" }, { "@type": "Person", "name": "Nematalla Sabir Balla" }, { "@type": "Person", "name": "Amro Abdelrahman" }, { "@type": "Person", "name": "Khalid Y Fadul" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": "Sodium-glucose co-transporter-2 (SGLT2) inhibitors are well-recognised antidiabetic medications among clinicians due to its highly protective effects on cardiovascular and renal systems on diabetic patients. However, one of its uncommonly reported side effects is the development of euglycemic diabetic ketoacidosis (EuDKA) which is characterized by mild hyperglycemia, ketosis and acidosis. Chest pain as a clinical presentation of EuDKA has been rarely reported in the literature. We present a case of a 46-year-old female with a past medical history of type 2 diabetes mellitus (T2DM), hypertension, and hypertriglyceridemia presented to the hospital with central chest pain that radiates to the back and is associated with mild shortness of breath and one bout of vomiting. She had been taking dapagliflozin, an SGLT2 inhibitor, for four years. She was found to have a blood glucose level of 7 mmol\L, high anion gap metabolic acidosis and ketonuria. Toxicology screening was unremarkable. She was diagnosed as a case of SGLT2-induced EuDKA and was treated with fluid, insulin and potassium chloride (KCL). Her hospital course went smoothly. Dapagloflzi was discontinued, and she was discharged home on oral metformin and subcutaneous insulin. This study highlights the rare occurance of chest pain as a presentation of EuDKA, an uncommon side effect of the widely used SGLT2 inhibitors. Chest pain in patients using SGLT2 Inhibitors should raise the clinician’s suspicion for possible EuDKA." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-1157/v2", "name": "Case Report: Chest Pain as an Uncommon Presentation for Euglycemic..." } } ] } Home Browse Case Report: Chest Pain as an Uncommon Presentation for Euglycemic... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article M. Abbas S, Jamal A.bagi F, Abdalkarim A et al. Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.12688/f1000research.139928.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] Shahd M. Abbas 1 , Fajr Jamal A.bagi https://orcid.org/0009-0007-9643-5381 2 , Asmaa Abdalkarim https://orcid.org/0009-0008-5999-7948 3 , Nematalla Sabir Balla 4 , Amro Abdelrahman https://orcid.org/0000-0003-3113-3431 5 , Khalid Y Fadul 6 Shahd M. Abbas 1 , Fajr Jamal A.bagi https://orcid.org/0009-0007-9643-5381 2 , [...] Asmaa Abdalkarim https://orcid.org/0009-0008-5999-7948 3 , Nematalla Sabir Balla 4 , Amro Abdelrahman https://orcid.org/0000-0003-3113-3431 5 , Khalid Y Fadul 6 PUBLISHED 30 May 2024 Author details Author details 1 Hamad Medical Corporation, Doha, Doha, Qatar 2 Hamad Medical Corporation, Doha, Doha, Qatar 3 Hamad Medical Corporation, Doha, Doha, Qatar 4 Hamad Medical Corporation, Doha, Doha, Qatar 5 Hamad Medical Corporation, Doha, Doha, Qatar 6 Hamad Medical Corporation, Doha, Doha, Qatar Shahd M. Abbas Roles: Writing – Original Draft Preparation, Writing – Review & Editing Fajr Jamal A.bagi Roles: Writing – Original Draft Preparation Asmaa Abdalkarim Roles: Writing – Original Draft Preparation Nematalla Sabir Balla Roles: Writing – Original Draft Preparation Amro Abdelrahman Roles: Writing – Original Draft Preparation, Writing – Review & Editing Khalid Y Fadul Roles: Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Sodium-glucose co-transporter-2 (SGLT2) inhibitors are well-recognised antidiabetic medications among clinicians due to its highly protective effects on cardiovascular and renal systems on diabetic patients. However, one of its uncommonly reported side effects is the development of euglycemic diabetic ketoacidosis (EuDKA) which is characterized by mild hyperglycemia, ketosis and acidosis. Chest pain as a clinical presentation of EuDKA has been rarely reported in the literature. We present a case of a 46-year-old female with a past medical history of type 2 diabetes mellitus (T2DM), hypertension, and hypertriglyceridemia presented to the hospital with central chest pain that radiates to the back and is associated with mild shortness of breath and one bout of vomiting. She had been taking dapagliflozin, an SGLT2 inhibitor, for four years. She was found to have a blood glucose level of 7 mmol\L, high anion gap metabolic acidosis and ketonuria. Toxicology screening was unremarkable. She was diagnosed as a case of SGLT2-induced EuDKA and was treated with fluid, insulin and potassium chloride (KCL). Her hospital course went smoothly. Dapagloflzi was discontinued, and she was discharged home on oral metformin and subcutaneous insulin. This study highlights the rare occurance of chest pain as a presentation of EuDKA, an uncommon side effect of the widely used SGLT2 inhibitors. Chest pain in patients using SGLT2 Inhibitors should raise the clinician’s suspicion for possible EuDKA. READ ALL READ LESS Keywords Diabetes, SGLT2, EuDKA, Chest pain Corresponding Author(s) Khalid Y Fadul ( [email protected] ) Close Corresponding author: Khalid Y Fadul Competing interests: No competing interests were disclosed. Grant information: Open Access funding provided by Qatar National Library. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 M. Abbas S 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 work is properly cited. How to cite: M. Abbas S, Jamal A.bagi F, Abdalkarim A et al. Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.12688/f1000research.139928.2 ) First published: 15 Sep 2023, 12 :1157 ( https://doi.org/10.12688/f1000research.139928.1 ) Latest published: 30 May 2024, 12 :1157 ( https://doi.org/10.12688/f1000research.139928.2 ) Revised Amendments from Version 1 Here, we added important information based on the recommendation of the reviewer for clarification of insulin duration. The added text is under the case presentation subheading. In the section, we describe the management of the patient. Here, we added important information based on the recommendation of the reviewer for clarification of insulin duration. The added text is under the case presentation subheading. In the section, we describe the management of the patient. See the authors' detailed response to the review by Rebecca J Vitale READ REVIEWER RESPONSES Introduction Diabetic ketoacidosis (DKA) is one of the frequent complications of diabetes mellitus (DM), and it is characterized by the presence of hyperglycemia, ketosis, and high anion gap metabolic acidosis. Unlike DKA, euglycemic diabetic ketoacidosis (EuDKA) is characterized by a blood glucose level <11.1 mmol/L. 1 EuDKA is an uncommon diagnosis with an incidence ranging between 2.6% to 3.2% of admissions. 2 Sodium-glucose cotransporter-2 (SGLT2) inhibitors are relatively new antihyperglycemic medications that were introduced into the market in the last decade. 3 Due to its scientifically proven cardiac and renal protective effects in diabetic patients, it has gained a lot of popularity in clinical practice. However, as with any medication, there’s a risk of side effects, and one of its rarely reported side effects is the development of euglycemic diabetic ketoacidosis. 4 Typically, EuDKA presents clinically with symptoms similar to those of DKA, such as nausea, vomiting, and abdominal pain. 4 Furthermore, chest pain as a presenting symptom for EuDKA is relatively rare, and only a few cases have been reported in the literature. In this case report, we are reporting a 46-year-old female with a past medical history of type 2 diabetes mellitus (T2DM) on SGLT2 inhibitor (Dapagliflozin) therapy for three years who presented to the hospital with central chest pain radiating to the back associated with shortness of breath and vomiting and was found to have high anion gap metabolic acidosis. She was diagnosed as a case of SGLT2 inhibitor-induced euglycemic DKA after excluding all other possible etiologies of EuDKA. Case presentation A 46-year-old non-pregnant Indian female with a past medical history of type 2 diabetes mellitus, hypertension, and hypertriglyceridemia presents to the hospital with central chest pain that radiates to the back and is associated with mild shortness of breath and one bout of vomiting. According to the patient, the pain has been present for more than a week but has significantly increased in the past two days. She denied any history of coughing, paroxysmal nocturnal dyspnea, or orthopnea. A review of other systems revealed no abnormalities. The patient denied any recent change in her diet or exercise, as well as her alcohol intake. She has had type 2 diabetes mellitus for more than six years, which has been previously treated. Four years ago she started taking an SGLT2 inhibitor, dapagliflozin (10 mg), but she has not improved her lifestyle and is not taking her medications consistently, and her HbA1C has consistently been elevated (11.3%). In addition to dapagliflozin, she was taking fenofibrate (200 mg) for hypertriglyceridemia and lisinopril-hydrochlorothiazide (20 mg/12.5 mg) for hypertension. In the emergency department, her blood pressure was 156/82 mmHg, her temperature was 36.8 °C , her heart rate was 91 beats per minute, her respiratory rate was 19 breaths per minute, and her oxygen saturation (SpO 2 ) was 99% on room air. On physical examination, she was mildly distressed, and auscultation of the lung revealed clear lung fields with no rhonchi or crackles. A cardiac examination showed normal S1 and S2 with no added sounds. Examination of other systems was unremarkable. Two sets of troponin T enzymes were within the normal range (9 ng/dl), and her electrocardiogram (ECG) showed normal sinus rhythm with no ST changes. The result of the chest X-ray was unremarkable. A computed tomography (CT) scan was done, and it showed no evidence of pulmonary embolism (PE). A point-of-care venous blood gas test (VBG) result showed a blood glucose level of 7.7 mmol/L, a pH of 7.24, a PCO 2 level of 19 mmHg, a HCO 3 level of 13 mmHg, and a beta-hydroxybutyrate level of 3.2 mmol. Results of the basic metabolic panel showed a sodium (Na) level of 134 mmol/L, a potassium (K) level of 4 mmol/L, a chloride (Cl) level of 101 mmol/L, and a bicarbonate level of 13 mmol/L with a calculated anion gap of 20. Her lipid profile results showed triglyceride levels of 14.6 mmol/L, cholesterol levels of 9.6 mmol/L, and low-density lipoprotein levels of 4.8 mmol/L. In addition to that, high levels of glucosuria (+2) and ketonuria (+4) were also detected in the patient’s urine. A toxicology screening result showed normal levels of acetaminophen, ethanol, and salicylate. A diagnosis of SGLT2 inhibitor-induced euglycemic DKA (EuDKA) was made, and the patient started on IV fluid therapy with 0.45% sodium chloride (NaCL) with 5% dextrose (D5) (250 ml/hr), insulin infusion of 0.1 units/kg/hr, and potassium chloride (KCL) infusion of 20 mEq/L (125 ml/min) according to the local protocol. The patient was admitted to the medical floor for more observation and the potassium chloride (KCL) infusion was escalated to 40 mEq/L. She was on insulin infusion for 16 hours then shifted to subcutaneous insulin. Two days later, the patient’s chest pain improved, she was tolerating food, her lab results showed an HCO 3 level of 23 mmol/L, and the anion gap was closed. Dapagliflozin was discontinued, and she was discharged home on oral metformin 500 mg, subcutaneous insulin aspart 20 units, and subcutaneous insulin glargine 30 units. She was advised to use a glucometer at home to monitor and record her blood glucose levels. A follow-up appointment was scheduled at the general medicine clinic. During her follow-up visit, the patient’s home readings were within the normal range. Discussion Euglycemic DKA (EuDKA) is a life-threatening condition that needs emergent management. It may occur in type 1 or type 2 DM, and it’s characterized by milder degrees of hyperglycemia with blood glucose levels <11.1 mmol/l, which can result in delayed diagnosis and treatment with potentially adverse metabolic consequences. 1 Numerous conditions were reported to trigger euglycemic DKA, such as inadequate oral intake, insulin treatment before arrival at the emergency department, pregnancy, and sodium-glucose co-transporter 2 (SGLT2) inhibitors. 5 The latest was the probable cause of our patient’s illness. It’s worth mentioning that EuDKA does not necessarily present typical manifestations of DKA. In which marked hyperglycemia and the resultant dehydration are the usual causes. For example, patients with EuDKA treated with SGLT2 inhibitors may have less polyuria and polydipsia due to the milder degree of hyperglycemia, and these patients may only present with malaise, anorexia, tachycardia, or tachypnea with or without fever. 6 However, chest pain as a manifestation of EuDKA or DKA has rarely been reported in the literature. A previous study reported a case of EuDKA presenting with chest pain in diabetic patients using SGLT2 inhibitor therapy who had recently started a ketogenic diet. 7 In our case, the patient denied any recent changes in her diet. Another study also reported a case of DKA presenting with chest pain after skipping insulin therapy while fasting. She was found to have a high blood glucose level of 17.1 mmol/L. 8 Unlike our patient, who was only on SGLT2 therapy and had a blood glucose level of 7.7 mmol/L. Moreover, a case of ST-segment elevation myocardial infarction (STEMI) induced by SGLT2 inhibitor therapy presenting with chest pain has also been reported. 9 In contrast, our patient presented with chest pain, but his ECG showed no ST-segment changes. The presence of hypertriglyceridemia has been associated with lower levels of blood glucose in EuDKA. The concomitant presence of hypertriglyceridemia and SGLT2-induced EuDKA has been previously reported in the literature. 10 Although our patient had a very high level of triglyceride (14.6 mmol/L), it remains uncertain if his high triglyceride levels have contributed to his EuDKA. SGLT2 inhibitors were approved by the Food and Drug Administration (FDA) in 2013. Their main mechanism of action aims to reduce glucose reabsorption by targeting the kidneys. SGLT2 proteins normally facilitate the reabsorption of glucose back into plasma, inhibiting this process leads to glucosuria and in turn lowering serum glucose levels. SGLT2 inhibitors are an effective class of agents for controlling blood glucose levels in T2DM. Evidence in literature showed significantly improved outcomes in diabetics with cardiovascular disease, including decreased stroke and myocardial infarction related mortality. 11 SGLT2 inhibitors also impose a reduced risk of hypoglycemia, 12 unlike other hypoglycemic agents. Considering the desirable outcome associated with SGLT2 inhibitors they are often preferred by doctors and patients. However, our case represents a rare undesirable outcome which is EuDKA. The pathophysiology of EuDKA in SGLT2 inhibitor users is believed to be a result of hormonal adaptations involved in glucose metabolism in response to increased urinary excretion of glucose. Low glucose in serum reduces insulin secretion from beta-cells. The low insulin levels result in fatty acid accumulation due to increased lipolysis activity; fatty acids are converted to ketone bodies by Beta- oxidation in hepatocytes. Previous evidence suggests that SGLT2 inhibitors induce glucagon secretion from alpha- cells by direct stimulation of pancreas or either by secondary stimulation as a consequence of reduced insulin levels. 13 SGLT2 inhibitors mimic starvation conditions by inhibiting glucose resorption, this leads to increased ketone production and resorption in blood. 14 As a result the body is predisposed to acidemia by ketogenesis and the ongoing glucosuria results in normal to mildly elevated glucose serum levels manifesting as EuDKA. It is also important to note the mechanism behind hypertriglyceridemia observed in our patient. Increased lipolysis leads to formation of free fatty acids being transported into the liver and forming high levels of low density lipoproteins (LDL), reflecting high triglycerides levels in blood. 10 The management of EuDKA is similar to the management of DKA. The end goal of the treatment is to close the anion gap, address the electrolyte imbalance through insulin therapy, and correct dehydration through appropriate fluid resuscitation. However, it’s very important to maintain potassium levels between 4-5 while receiving insulin therapy, as it can result in hypokalemia and subsequent life-threatening arrhythmias. In addition, addressing the underlying triggers is a cornerstone of management. 15 Our patient was successfully managed with fluid therapy, insulin infusion, and potassium chloride, and her 2-day hospital course went smoothly; her chest pain had significantly improved, and she was tolerating food. Her lab results revealed an HCO3 level of 23, and she was discharged home on oral metformin and subcutaneous insulin, with discontinuation of dapagliflozin. She was advised to monitor her blood glucose level at home. On the follow up visit, the recorded result were within normal ranges. Conclusion EuDKA is a serious medical emergency that carries a sizable risk of delayed diagnosis and management, which could have detrimental metabolic effects. The wide use of SGLT2 inhibitors among diabetic patients has been linked with development of EuDKA. Furthermore, chest pain as presenting symptoms in patients using SGLT2 inhibitors should be carefully evaluated by clinician for possible EuDKA. Consent Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. Data availability All data underlying the results are available as part of the article and no additional source data are required. Reporting guidelines Zenodo: CARE checklist for “Chest pain as an uncommon presentation for euglycemic diabetic ketoacidosis in a female patient using SGLT2 inhibitor: Case report”. DOI: 10.5281/zenodo.8248574 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments Open Access funding provided by Qatar National Library. References 1. Barski L, Eshkoli T, Brandstaetter E, et al. : Euglycemic diabetic ketoacidosis. Eur. J. Intern. Med. 2019 May; 63 : 9–14. Publisher Full Text 2. Jenkins D, Close CF, Krentz AJ, et al. : Euglycaemic diabetic ketoacidosis: does it exist? Acta Diabetol. 1993; 30 (4): 251–253. PubMed Abstract | Publisher Full Text 3. Iqbal I, Hamid M, Khan MAA, et al. : Dapagliflozin-induced Late-onset Euglycemic Diabetic Ketoacidosis. Cureus. 2019 Nov 7; 11 (11): e6089. PubMed Abstract | Publisher Full Text | Free Full Text 4. Somagutta MR, Pormento MKLL, Hange N, et al. : Patient-Specific Risk Factors and Clinical Correlates of Euglycemic Diabetic Ketoacidosis in Patients on Sodium-Glucose Co-Transporter-2 Inhibitors. J. Endocr. Soc. 2021; 5 (Suppl 1): A473. Publisher Full Text 5. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: treatment. UpToDate. [updated 2021 Jan 22; cited 2021 Feb 15]. Reference Source 6. Nasa P, Chaudhary S, Shrivastava PK, et al. : Euglycemic diabetic ketoacidosis: A missed diagnosis. World J. Diabetes. 2021 May 15; 12 (5): 514–523. PubMed Abstract | Publisher Full Text | Free Full Text 7. Dorcely B, Nitis J, Schwartzbard A, et al. : A Case Report: Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain in a Patient on a Low Carbohydrate Diet. Curr. Diabetes Rev. 2021; 17 (2): 243–246. PubMed Abstract | Publisher Full Text | Free Full Text 8. Mohamad NAR, Cheah PK: Chest pain in emergency department: A diagnosis of diabetic ketoacidosis must be ruled out. Int. J. Case Rep. Imag. 2010; 1 (3): 6–9. Publisher Full Text 9. Zughaib M, Basharat B, Small D: A Case of STEMI-Induced Euglycemic Diabetic Ketoacidosis in a Patient Receiving a Sodium Glucose Cotransporter-2 Inhibitor. JACC Case Rep. 2023 Feb 18; 11 : 101792. PubMed Abstract | Publisher Full Text | Free Full Text 10. Gajjar K, Luthra P: Euglycemic Diabetic Ketoacidosis in the Setting of SGLT2 Inhibitor Use and Hypertriglyceridemia: A Case Report and Review of Literature. Cureus. 2019 Apr 4; 11 (4): e4384. PubMed Abstract | Publisher Full Text | Free Full Text 11. Zinman B, Wanner C, Lachin JM, et al. : Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N. Engl. J. Med. 2015 Nov 26; 373 (22): 2117–2128. Publisher Full Text 12. Clar C, Gill JA, Court R, et al. : Systematic review of SGLT2 receptor inhibitors in dual or triple therapy in type 2 diabetes. BMJ Open. 2012; 2 (5): e001007. PubMed Abstract | Publisher Full Text | Free Full Text 13. Bonner C, Kerr-Conte J, Gmyr V, et al. : Inhibition of the glucose transporter SGLT2 with dapagliflozin in pancreatic alpha cells triggers glucagon secretion. Nat. Med. 2015; 21 (5): 512–517. PubMed Abstract | Publisher Full Text 14. Qiu H, Novikov A, Vallon V: Ketosis and diabetic ketoacidosis in response to SGLT2 inhibitors: Basic mechanisms and therapeutic perspectives. Diabetes Metab. Res. Rev. 2017 Jul; 33 (5): e2886. PubMed Abstract | Publisher Full Text 15. Kitabchi AE, Umpierrez GE, Miles JM, et al. : Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul; 32 (7): 1335–1343. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Sep 2023 ADD YOUR COMMENT Comment Author details Author details 1 Hamad Medical Corporation, Doha, Doha, Qatar 2 Hamad Medical Corporation, Doha, Doha, Qatar 3 Hamad Medical Corporation, Doha, Doha, Qatar 4 Hamad Medical Corporation, Doha, Doha, Qatar 5 Hamad Medical Corporation, Doha, Doha, Qatar 6 Hamad Medical Corporation, Doha, Doha, Qatar Shahd M. Abbas Roles: Writing – Original Draft Preparation, Writing – Review & Editing Fajr Jamal A.bagi Roles: Writing – Original Draft Preparation Asmaa Abdalkarim Roles: Writing – Original Draft Preparation Nematalla Sabir Balla Roles: Writing – Original Draft Preparation Amro Abdelrahman Roles: Writing – Original Draft Preparation, Writing – Review & Editing Khalid Y Fadul Roles: Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Open Access funding provided by Qatar National Library. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 30 May 2024, 12:1157 https://doi.org/10.12688/f1000research.139928.2 version 1 Published: 15 Sep 2023, 12:1157 https://doi.org/10.12688/f1000research.139928.1 Copyright © 2024 M. Abbas S 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 work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article M. Abbas S, Jamal A.bagi F, Abdalkarim A et al. Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.12688/f1000research.139928.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 30 May 2024 Revised Views 0 Cite How to cite this report: Gupta R. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r358241 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-358241 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Feb 2025 Riya Gupta , Mayo Clinic, Rochester, Minnesota, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.167169.r358241 Peer Review for Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor SUMMARY: Case of a 46 y/o female who presented with chest pain and was diagnosed ... Continue reading READ ALL Peer Review for Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor SUMMARY: Case of a 46 y/o female who presented with chest pain and was diagnosed with EuDKA and treated for the same. “Unlike DKA, euglycemic diabetic ketoacidosis (EuDKA) is characterized by a blood glucose level <11.1 mmol/L” According to the reference, the glucose level should be below 11 mmol/L and not 11.1 mmol/L. Can the author clarify this? To add on, the author could benefit from adding the criteria required to be met to categorize the patient as EuDKA [BG of 10.] in the introduction and discussion. “Sodium-glucose cotransporter-2 (SGLT2) inhibitors are relatively new antihyperglycemic medications that were introduced into the market in the last decade.” Would not call SGLT2i relatively new since they have been around for more than a decade. Maybe can be rephrased along the lines of “Although the drug has been around for some time, there are new side effects that were not previously known and can be life threatening and hence why this case report is important” “Due to its scientifically proven cardiac and renal protective effects in diabetic patients, it has gained a lot of popularity in clinical practice” Please add reference for this. Cannot make such statements without evidence to back it. [can use this as a reference for cardiac mortality: Aktas G, Atak Tel BM, Tel R, et al [2023 (Ref-1)]. Treatment of type 2 diabetes patients with heart conditions. Expert Review of Endocrinology & Metabolism 2023; 18:255–65. doi:10.1080/17446651.2023.2204941 ]. A reference needs to be added for renal protective effects. “A computed tomography (CT) scan was done, and it showed no evidence of pulmonary embolism (PE)” A CT scan cannot rule out PE, unless it was a CT pulmonary angiography. If a CTPA was done, that should be mentioned, otherwise this statement is incorrect. What was the precipitating event? Was she asked about recent surgery, infection, pancreatitis, glycogen storage disorders, cocaine toxicity, cirrhosis, insulin pump use? Episodes can be triggered by surgery, infection, trauma, a major illness, reduced food intake, persistent vomiting, gastroparesis, dehydration, and reduced insulin dosages. If a CBC with differential count was done, please mention so as to rule out ongoing infection as a possible trigger for EuDKA. 0.45% sodium chloride (NaCL) with 5% dextrose (D5) (250 ml/hr), insulin infusion of 0.1 units/kg/hr, and potassium chloride (KCL) infusion of 20 mEq/L (125 ml/min) according to the local protocol. Although the local protocol is as mentioned above, the standard of care is to start with aggressive fluid resuscitation using isotonic fluids/lactated ringer and not 0.45% NaCl [Plewa MC et al. (2025[Ref-2]): Euglycemic Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf ]. For the pathophysiology provided in the discussion, please add necessary reference. “Her lab results revealed an HCO3 level of 23” This can be mentioned in the case presentation rather than the discussion. The entire last paragraph of discussion is more apt for the case presentation section of this case report and does not add value to the discussion. Minor Corrections Dapagliflozin has been misspelled in the abstract. Would recommend using references from the past 10 years at most whenever possible. Adjust keywords based on MeSH terms. The tenses need to be corrected to follow one tense (present or past). “It’s worth mentioning that EuDKA does not necessarily present typical manifestations of DKA. In which marked hyperglycemia and the resultant dehydration are the usual causes.” Please add correct punctuations. The authors could benefit from using a grammar checker to improve language. Recommend inserting references as the end of the sentence (can be edited according to journal guidelines). Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Aktas G, Atak Tel BM, Tel R, Balci B: Treatment of type 2 diabetes patients with heart conditions. Expert Rev Endocrinol Metab . 2023; 18 (3): 255-265 PubMed Abstract | Publisher Full Text 2. Plewa MC, Bryant M, King-Thiele R: Euglycemic Diabetic Ketoacidosis. StatPearls . 2025. Reference Source Competing Interests: No competing interests were disclosed. Reviewer Expertise: Medical research, more focused on gastroenterological disorders. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Gupta R. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r358241 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-358241 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Vitale RJ. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r284834 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-284834 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Jun 2024 Rebecca J Vitale , Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center,, Boston,, MA, USA Approved VIEWS 0 https://doi.org/10.5256/f1000research.167169.r284834 The authors did respond to my comments/questions in their response to reviewers, though they did not include all aspects ... Continue reading READ ALL The authors did respond to my comments/questions in their response to reviewers, though they did not include all aspects in their revision of the manuscript. As the review and response are published alongside the article, this is acceptable. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Diabetes I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vitale RJ. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r284834 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-284834 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 15 Sep 2023 Views 0 Cite How to cite this report: Vitale RJ. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.153249.r225909 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v1#referee-response-225909 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Dec 2023 Rebecca J Vitale , Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center,, Boston,, MA, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.153249.r225909 This case report details a 46-year-old woman with type 2 diabetes on SGLT2 inhibitor therapy who presented with chest pain and was found to have euglycemic DKA. The case is well-written and expands upon an unusual presentation of a rare ... Continue reading READ ALL This case report details a 46-year-old woman with type 2 diabetes on SGLT2 inhibitor therapy who presented with chest pain and was found to have euglycemic DKA. The case is well-written and expands upon an unusual presentation of a rare but severe medication side effect. Major comments Overall the manuscript is very well-written and clear. It wasn’t clear how long the patient required insulin infusion for the DKA to resolve. The case description notes that 2 days later her chest pain had improved and she was tolerating food, but I wouldn’t expect her to have required 48 hours of insulin infusion with a pH of only 7.24. There is no mention of the fact that hypertriglyceridemia can impact the accuracy of lab results. It would be beneficial to report whether the samples were processed in some way so as to limit the impact of lipemia on lab results and discuss whether any lab results may have been impacted by lipemia. A helpful reference is (Soleimani N et al,2020) The discussion would benefit from inclusion of a paragraph regarding the pathophysiology of why DKA may present with chest pain. Minor comments The report would benefit from grammatical editing, as there are some misspelled words, sentences that are not full sentences, and discrepancies in past vs present tense. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. Soleimani N, Mohammadzadeh S, Asadian F: Lipemia Interferences in Biochemical Tests, Investigating the Efficacy of Different Removal Methods in comparison with Ultracentrifugation as the Gold Standard. J Anal Methods Chem . 2020; 2020 : 9857636 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Diabetes I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Vitale RJ. Reviewer Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.153249.r225909 ) The direct URL for this report is: https://f1000research.com/articles/12-1157/v1#referee-response-225909 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 13 Apr 2024 Amro Abdelrahman , Hamad Medical Corporation, Doha, Qatar 13 Apr 2024 Author Response Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our ... Continue reading Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our case, hypertriglyceridemia didn't affect the accuracy of results. - Regarding the DKA and chest pain, we aren't completely sure whether it was due to the ketogensis inducing prothrombotic state and ischemia or it was as a result of chylomicronemia affecting blood circulation. We think this might need a seperate article with full discussion of different context of chest pain with DKA. Thanks for your feedback again, Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our case, hypertriglyceridemia didn't affect the accuracy of results. - Regarding the DKA and chest pain, we aren't completely sure whether it was due to the ketogensis inducing prothrombotic state and ischemia or it was as a result of chylomicronemia affecting blood circulation. We think this might need a seperate article with full discussion of different context of chest pain with DKA. Thanks for your feedback again, Competing Interests: No competing intersts to disclose Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 13 Apr 2024 Amro Abdelrahman , Hamad Medical Corporation, Doha, Qatar 13 Apr 2024 Author Response Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our ... Continue reading Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our case, hypertriglyceridemia didn't affect the accuracy of results. - Regarding the DKA and chest pain, we aren't completely sure whether it was due to the ketogensis inducing prothrombotic state and ischemia or it was as a result of chylomicronemia affecting blood circulation. We think this might need a seperate article with full discussion of different context of chest pain with DKA. Thanks for your feedback again, Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our case, hypertriglyceridemia didn't affect the accuracy of results. - Regarding the DKA and chest pain, we aren't completely sure whether it was due to the ketogensis inducing prothrombotic state and ischemia or it was as a result of chylomicronemia affecting blood circulation. We think this might need a seperate article with full discussion of different context of chest pain with DKA. Thanks for your feedback again, Competing Interests: No competing intersts to disclose Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Sep 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 30 May 24 read read Version 1 15 Sep 23 read Rebecca J Vitale , Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center,, Boston,, USA Riya Gupta , Mayo Clinic, Rochester, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Feb 2025 | for Version 2 Riya Gupta , Mayo Clinic, Rochester, Minnesota, USA 0 Views copyright © 2025 Gupta R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Peer Review for Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor SUMMARY: Case of a 46 y/o female who presented with chest pain and was diagnosed with EuDKA and treated for the same. “Unlike DKA, euglycemic diabetic ketoacidosis (EuDKA) is characterized by a blood glucose level <11.1 mmol/L” According to the reference, the glucose level should be below 11 mmol/L and not 11.1 mmol/L. Can the author clarify this? To add on, the author could benefit from adding the criteria required to be met to categorize the patient as EuDKA [BG of 10.] in the introduction and discussion. “Sodium-glucose cotransporter-2 (SGLT2) inhibitors are relatively new antihyperglycemic medications that were introduced into the market in the last decade.” Would not call SGLT2i relatively new since they have been around for more than a decade. Maybe can be rephrased along the lines of “Although the drug has been around for some time, there are new side effects that were not previously known and can be life threatening and hence why this case report is important” “Due to its scientifically proven cardiac and renal protective effects in diabetic patients, it has gained a lot of popularity in clinical practice” Please add reference for this. Cannot make such statements without evidence to back it. [can use this as a reference for cardiac mortality: Aktas G, Atak Tel BM, Tel R, et al [2023 (Ref-1)]. Treatment of type 2 diabetes patients with heart conditions. Expert Review of Endocrinology & Metabolism 2023; 18:255–65. doi:10.1080/17446651.2023.2204941 ]. A reference needs to be added for renal protective effects. “A computed tomography (CT) scan was done, and it showed no evidence of pulmonary embolism (PE)” A CT scan cannot rule out PE, unless it was a CT pulmonary angiography. If a CTPA was done, that should be mentioned, otherwise this statement is incorrect. What was the precipitating event? Was she asked about recent surgery, infection, pancreatitis, glycogen storage disorders, cocaine toxicity, cirrhosis, insulin pump use? Episodes can be triggered by surgery, infection, trauma, a major illness, reduced food intake, persistent vomiting, gastroparesis, dehydration, and reduced insulin dosages. If a CBC with differential count was done, please mention so as to rule out ongoing infection as a possible trigger for EuDKA. 0.45% sodium chloride (NaCL) with 5% dextrose (D5) (250 ml/hr), insulin infusion of 0.1 units/kg/hr, and potassium chloride (KCL) infusion of 20 mEq/L (125 ml/min) according to the local protocol. Although the local protocol is as mentioned above, the standard of care is to start with aggressive fluid resuscitation using isotonic fluids/lactated ringer and not 0.45% NaCl [Plewa MC et al. (2025[Ref-2]): Euglycemic Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf ]. For the pathophysiology provided in the discussion, please add necessary reference. “Her lab results revealed an HCO3 level of 23” This can be mentioned in the case presentation rather than the discussion. The entire last paragraph of discussion is more apt for the case presentation section of this case report and does not add value to the discussion. Minor Corrections Dapagliflozin has been misspelled in the abstract. Would recommend using references from the past 10 years at most whenever possible. Adjust keywords based on MeSH terms. The tenses need to be corrected to follow one tense (present or past). “It’s worth mentioning that EuDKA does not necessarily present typical manifestations of DKA. In which marked hyperglycemia and the resultant dehydration are the usual causes.” Please add correct punctuations. The authors could benefit from using a grammar checker to improve language. Recommend inserting references as the end of the sentence (can be edited according to journal guidelines). Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Aktas G, Atak Tel BM, Tel R, Balci B: Treatment of type 2 diabetes patients with heart conditions. Expert Rev Endocrinol Metab . 2023; 18 (3): 255-265 PubMed Abstract | Publisher Full Text 2. Plewa MC, Bryant M, King-Thiele R: Euglycemic Diabetic Ketoacidosis. StatPearls . 2025. Reference Source Competing Interests No competing interests were disclosed. Reviewer Expertise Medical research, more focused on gastroenterological disorders. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Gupta R. Peer Review Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r358241) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-358241 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Vitale R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Jun 2024 | for Version 2 Rebecca J Vitale , Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center,, Boston,, MA, USA 0 Views copyright © 2024 Vitale R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors did respond to my comments/questions in their response to reviewers, though they did not include all aspects in their revision of the manuscript. As the review and response are published alongside the article, this is acceptable. Competing Interests No competing interests were disclosed. Reviewer Expertise Diabetes I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Vitale RJ. Peer Review Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.167169.r284834) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1157/v2#referee-response-284834 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Vitale R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Dec 2023 | for Version 1 Rebecca J Vitale , Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center,, Boston,, MA, USA 0 Views copyright © 2023 Vitale R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report details a 46-year-old woman with type 2 diabetes on SGLT2 inhibitor therapy who presented with chest pain and was found to have euglycemic DKA. The case is well-written and expands upon an unusual presentation of a rare but severe medication side effect. Major comments Overall the manuscript is very well-written and clear. It wasn’t clear how long the patient required insulin infusion for the DKA to resolve. The case description notes that 2 days later her chest pain had improved and she was tolerating food, but I wouldn’t expect her to have required 48 hours of insulin infusion with a pH of only 7.24. There is no mention of the fact that hypertriglyceridemia can impact the accuracy of lab results. It would be beneficial to report whether the samples were processed in some way so as to limit the impact of lipemia on lab results and discuss whether any lab results may have been impacted by lipemia. A helpful reference is (Soleimani N et al,2020) The discussion would benefit from inclusion of a paragraph regarding the pathophysiology of why DKA may present with chest pain. Minor comments The report would benefit from grammatical editing, as there are some misspelled words, sentences that are not full sentences, and discrepancies in past vs present tense. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. Soleimani N, Mohammadzadeh S, Asadian F: Lipemia Interferences in Biochemical Tests, Investigating the Efficacy of Different Removal Methods in comparison with Ultracentrifugation as the Gold Standard. J Anal Methods Chem . 2020; 2020 : 9857636 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Diabetes I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 13 Apr 2024 Amro Abdelrahman, Hamad Medical Corporation, Doha, Qatar Dear reviewer. Thanks for feedback. - Patient was on insulin infusion for 16 hours then shifted to subcutaneous insulin. This will be added to case presentation. - In our case, hypertriglyceridemia didn't affect the accuracy of results. - Regarding the DKA and chest pain, we aren't completely sure whether it was due to the ketogensis inducing prothrombotic state and ischemia or it was as a result of chylomicronemia affecting blood circulation. We think this might need a seperate article with full discussion of different context of chest pain with DKA. Thanks for your feedback again, View more View less Competing Interests No competing intersts to disclose reply Respond Report a concern Vitale RJ. Peer Review Report For: Case Report: Chest Pain as an Uncommon Presentation for Euglycemic Diabetic Ketoacidosis in a Female Patient Using SGLT2 inhibitor [version 2; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 12 :1157 ( https://doi.org/10.5256/f1000research.153249.r225909) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1157/v1#referee-response-225909 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });