2026 Volume 29 Issue 1 Pages 75-79
A woman in her 60s was transported with several days of vomiting, diarrhea, poor appetite, and fever followed by altered mental status. She was managed in the ICU for presumed sepsis-related shock with metabolic acidosis. The ICU-dedicated clinical pharmacist reconciled her regular medications and identified a fixed-dose combination of the SGLT2 inhibitor ipragliflozin with sitagliptin, prompting concern for euglycemic diabetic ketoacidosis (euDKA). The pharmacist recommended ketone testing, which confirmed marked ketonemia. Insulin with dextrose, fluid resuscitation, and electrolyte replacement improved the acidosis. Because hypotension persisted despite vasopressors, the pharmacist suggested evaluation for adrenal insufficiency; testing revealed low ACTH and low cortisol. Hydrocortisone plus vasopressin stabilized hemodynamics. As pharmacist coverage in emergency departments remains limited, round-the-clock deployment could facilitate accurate medication histories, earlier detection of adverse drug effects, and more appropriate selection of pharmacotherapy.
