T1D Patient Develops Diabetic Ketoacidosis After Starting Obesity Drug
Amphetamine-like analogues as a short term adjunct in management of exogenous obesity have several absolute contraindications like history of cardiovascular disease and hyperthyroidism, but not diabetes. A case study in Case Reports in Endocrinology describes a patient with a history of type 1 diabetes who experienced diabetic ketoacidosis (DKA) after starting diethylpropion HCI for weight loss.
A 34-year-old female presented with nausea, vomiting, and severe, cramping periumbilical abdominal pain; she had been diagnosed with type 1 diabetes at age 24 and had been using an insulin pump for two years. She frequently skipped mealtime insulin that led to poor diabetes control and her last HbA1C was 9.2%. In addition to the insulin aspart, her medications included rosuvastatin 5mg daily and she had been prescribed diethylpropion 75mg daily by her primary medical doctor 10 days prior. Before arriving at the hospital, her fingerstick blood glucose was ≈400mg/dL so the patient changed the insulin pump site and administered several insulin boluses manually through the pump. No improvements in blood glucose were observed so she administered an injection of a short-acting insulin – yet, she continued to experience significant hyperglycemia, nausea, vomiting, and abdominal pain.
Blood work showed glucose of 718mg/dL, pH 7.32 (7.35–7.45), bicarbonate 16mmol/L (22–29mmol/L), and anion gap 19mmol/L (8–16mmol/L) while a urine analysis demonstrated large amount of ketones. After being admitted to the hospital she was treated for DKA and was transitioned back to her insulin pump after DKA resolution. Diethylpropion was discontinued.
Amphetamine-like analogues such as diethylpropion suppress appetite via norepinephrine release from the lateral hypothalamus while peripheral norepinephrine concentration increases as well. Norepinephrine boosts beta-oxidation of nonesterified fatty acids (NEFA) to ketone bodies while lowering metabolic clearance rate of ketones; in acute insulin deficiency, these effects can be particularly evident in females. When prescribing amphetamine-like analogues to patients with type 1 diabetes, clinicians should be aware of the possibility of ketosis, particularly with insulin deficiency.
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