Diabetic Review of Systems

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Eyes: The patient obtains annual eye exams, with no reported retinopathy.

Cardiac: No coronary artery disease. History of hypertension on valsartan-HCTZ.

Sleep: History of sleep apnea, wearing a CPAP daily with reported 100% compliance.

Renal: Microalbuminuria 22.3 mg/day in the last year. Creatinine 1.2 mg/dL with an estimated GFR >60 on admission.

Hospital Course

Following percutaneous nephrolithotomy and stone extraction, infectious disease was consulted for treatment of a fungal urinary tract infection. In relation to diabetes, the patient was dismissed on preadmission metformin, insulin glargine injection, and set doses of rapid-acting insulin with meals. A discussion with his urology team took place, and it was believed that use of canagliflozin, a sodium-glucose co-transporter-2 (SGLT2) inhibitor, could have contributed to his persistent funguria. He was instructed to meter glucose values 4 times daily and received education regarding insulin dose adjustment. It was recommended that he follow up with a home endocrinology provider for ongoing diabetes recommendations and management.

The patient had additional follow-up within 2 months. At that time, he continued to take insulin glargine injection and rapid-acting insulin at mealtimes and metformin. His reported blood glucose range was 120 to 140 mg/dL at follow-up, and hemoglobin A1c was reduced about 3 points in the 8% range with no incidence of hypoglycemia.

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Clinical Pearl

It is important to know about the mechanism of action of medications. Specifically, SGLT2 inhibitors work by inhibiting SGLT2 in the proximal convoluted tubule of the kidney to prevent reabsorption of glucose and facilitate its excretion in urine. As glucose is excreted, its plasma levels decrease, leading to an improvement in blood glucose. With this excretion of glucose, urogenital tract infections are the most frequently noticed adverse events in subjects on SGLT2 agents. Commonly recommended for patients on these agents is adequate perineal hygiene and treatment with antifungal therapy.

Jennifer Freitag, APRN, CNP, and Jennifer Grenell, APRN, CNP, are nurse practitioners specializing in diabetes management at the Mayo Clinic, Department of Endocrinology, in Rochester, Minn.