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Risk Factors for Developing EKA SGLT-2 or GLP-1 usage (SGLT-2s are more strongly associated than GLP-1s) Higher medication doses Any action or condition that increases ketone production, including: Fasting (e.g., intermittent fasting, preoperative/preprocedural fasting) Ketogenic diet Gastrointestinal illness (poor appetite, nausea, vomiting, diarrhea) Eating disorders (anorexia/bulimia) Alcohol intoxication Liver cirrhosis Pancreatitis Gastroparesis Insulin pump malfunction Low muscle mass Recent infection or surgery Type 2 diabetes with longstanding poor glucose control Prevention Strategies Emphasize the importance of hydration with water and electrolyte solutions Minimize alcohol intake Ensure meals and snacks contain 3035% carbohydrate content Avoid ketogenic or prolonged fasting diets Clinicians should consider temporarily discontinuing SGLT-2 and GLP-1 therapy before surgery or during acute illness Patients should not decrease basal insulin dose by more than 20% without consulting their provider Patients should avoid taking these medications within 3 days prior to fasting longer than overnight Symptoms of EKA Fruity-smelling breath Excessive thirst Polyuria or nocturia Nausea and vomiting Abdominal pain Confusion or altered mental status Fever Shortness of breath Patient Education and Action Patients taking SGLT-2 or GLP-1 medications should be instructed that if they experience nausea, vomiting, or diarrhea: Sip calorically dense electrolyte solutions (approximately 200 mL every 30 minutes), or Suck on hard candy, or Consume one tablespoon of sugar every 1520 minutes If symptoms persist, patients should withhold further doses of the medication and contact their primary care provider or seek emergency care

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Easy measuring: At 1.667 mg/mL, 1 unit = 0.01 mL 16.67 mcg on a U100 insulin syringe

In mice with an intact intestinal microbiota, dietary supplementation with TMAO or either carnitine or choline reduced in vivo reverse cholesterol transport