An Unusual Case of the "Terrible Triad" in a Transgender Woman

Area of Science:

• Endocrinology
• Metabolic Disorders
• Pharmacology

Background:

• Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are increasingly used for type 2 diabetes and heart failure.
• Euglycemic diabetic ketoacidosis (DKA) is a rare but serious side effect of SGLT2i therapy.
• The triad of euglycemic DKA, acute pancreatitis, and hypertriglyceridemia (HTG) has complex and often unknown triggers.

Observation:

• A case of euglycemic DKA in a transgender woman using canagliflozin is presented.
• The patient also had hypertriglyceridemia and gallstone formation.
• Estrogen supplementation was identified as a potential contributing factor to HTG and gallstones.

Findings:

• The patient was successfully treated with dextrose and insulin infusions, alongside apheresis.
• Estrogen-induced hypertriglyceridemia may precipitate the disease triad in patients on SGLT2 inhibitors.
• This case illustrates a unique interplay of factors leading to euglycemic DKA.

Implications:

• Clinicians must be aware of euglycemic DKA as a potential SGLT2i side effect.
• Understanding contributing factors like estrogen therapy is crucial for managing complex cases.
• This case broadens the understanding of DKA triggers in patients with diabetes and cardiovascular conditions.