2025 Southeastern Residency Conference

Abstract Title: 
Evaluation of Hospital Admissions for Diabetic Ketoacidosis Following the Initiation of Empagliflozin in a Veteran Population
 
Authors: Connor Landers, Rose Weldon
 
Background/Purpose: 
Empagliflozin is a sodium-glucose co-transporter 2 inhibitor (SGLT2) that is commonly utilized in the treatment of type-2 diabetes, chronic kidney disease, and in the setting of heart failure to reduce hospitalizations and mortality. Diabetic Ketoacidosis (DKA) is a life-threatening emergency that can be a challenging diagnosis for many practitioners. The purpose of this project is to retrospectively evaluate the prevalence of hospitalizations at the Birmingham VA Healthcare System (BVAHCS) for DKA in veterans currently prescribed empagliflozin.
 
Methods:
This quality improvement project was a single center, retrospective observational chart review. Data obtained was collected from October 2023 to January 2025. Two separate groups of veterans were identified on initial data extraction. Group one consisted of veterans with an active empagliflozin prescription within 90 days prior to admission. Patients in this group were also included based on the day supply of their prescription plus an additional 30 days to account for potential mailing issues or non-adherence. Group two consisted of veterans not prescribed empagliflozin. From these two groups, all veterans were sorted by admission diagnosis, labs, or the need for an insulin drip during admission. Veterans were included within this study based on their diagnosis of DKA during admission, a calculated anion gap > 12, the presence of ketones on urinalysis, a detectable beta-hydroxybutyric acid, or the initiation of an insulin drip during admission. Veterans were excluded if they had type-1 diabetes or were followed by palliative/hospice care. The primary endpoint was the rate of DKA occurrence in patients prescribed empagliflozin compared to veterans not on the medication. The secondary endpoint was the average duration of hospitalization. Other observations included the average blood glucose level noted on admission, whether the patient received treatment, the percent of empagliflozin discontinuations at discharge, the appropriate reporting to the VA Adverse Drug Event Reporting System (VADERS), and mortality rates.
 
Results:
From the initial data extrapolation, a total of 7,560 admissions were identified for the prespecified groups. The VA Adverse Drug Event Report for all adverse drug events (ADE) attributed to empagliflozin during the specified period was extracted for comparison to help ensure reported incidences of DKA were not missed.  A total of 151 ADE reports were identified of which 18 total incidences of DKA (11.9% of total ADE reports for empagliflozin) were extracted and further analyzed. Overall, 59 total patient charts were included into this project’s final analysis of data. On average, patients on empagliflozin and admitted for DKA were found to be 67 years of age and the majority were male (84.6%). The overall incidence of DKA between groups was determined to be 2.38% (27 of 1,134 admissions) in patients on empagliflozin and 0.56% (36 of 6,426 admissions) in patients who were not prescribed the medication. Our secondary endpoint, the duration of hospitalization, was similar between both groups (7.6 days vs 7.9 days). Other observations included a lower average blood glucose on admission for patients on empagliflozin (339 mg/dL vs 551 mg/dL), 96% of patients on empagliflozin were treated, empagliflozin was discontinued in 89% of veterans at discharge, and only 11% of patients experienced mortality. One substantial finding of this project noted only 59% of DKA admissions for patients on empagliflozin were appropriately reported to VADERS.

Conclusion:
A higher prevalence of DKA admissions was observed in the sodium-glucose cotransporter-2 inhibitor (SGLT2) group as compared to veterans not taking the medication. This project identified high rates of patients receiving treatment in some capacity; however, adverse drug event reporting was found to be substantially low. Based on the findings of this project further education to providers, pharmacists, and patients can help improve identification and reporting of DKA within the BVAHCS.