{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T20:30:26Z","timestamp":1786480226610,"version":"build-2736575974"},"reference-count":0,"publisher":"Ovid Technologies (Wolters Kluwer Health)","license":[{"start":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T00:00:00Z","timestamp":1781481600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["Kidney360"],"abstract":"<jats:p>Enfortumab vedotin (EV), an antibody\u2013drug conjugate (ADC) approved for metastatic urothelial carcinoma, is increasingly recognized to cause severe hyperglycemia and diabetic ketoacidosis (DKA). However, optimal management of EV-associated refractory DKA remains undefined. We describe a 57-year-old man receiving EV and pembrolizumab who developed profound insulin-resistant DKA that persisted despite standard therapy. EV is composed of a nectin-4\u2013targeted monoclonal antibody linked to the cytotoxic agent monomethyl auristatin E (MMAE), which is the primary cause of systemic toxicity. Systemic elimination of MMAE is via metabolism by cytochrome P450 (CYP) 3A4 and biliary\/fecal excretion. Tissue exposure is limited via P-glycoprotein efflux pump. Therefore, in the setting of refractory DKA, a pharmacologic enzyme induction was initiated to mitigate further MMAE-induced injury. Following initiation of induction alongside continued insulin therapy, resolution of ketoacidosis occurred within 46 hours. This case illustrates a pharmacokinetic-informed approach to EV-associated refractory DKA and highlights how understanding drug metabolism may improve therapeutic outcomes when conventional therapy is insufficient.<\/jats:p>","DOI":"10.34067\/kid.0000001262","type":"journal-article","created":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T16:00:48Z","timestamp":1781539248000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Refractory Diabetic Ketoacidosis Associated with Enfortumab Vedotin"],"prefix":"10.34067","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7538-4596","authenticated-orcid":false,"given":"Shivangi K.","family":"Patel","sequence":"first","affiliation":[{"name":"Morristown Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7428-5393","authenticated-orcid":false,"given":"Taylor","family":"Purzycki","sequence":"additional","affiliation":[{"name":"Morristown Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-9996-8272","authenticated-orcid":false,"given":"Alaa","family":"Mahmoud","sequence":"additional","affiliation":[{"name":"Morristown Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-7947-2460","authenticated-orcid":false,"given":"John","family":"Saldarini","sequence":"additional","affiliation":[{"name":"Morristown Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,6,15]]},"container-title":["Kidney360"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0000001262","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T19:58:36Z","timestamp":1786478316000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.34067\/KID.0000001262"}},"subtitle":["A Pharmacokinetic-Based Management Approach"],"short-title":[],"issued":{"date-parts":[[2026,6,15]]},"references-count":0,"URL":"https:\/\/doi.org\/10.34067\/kid.0000001262","relation":{},"ISSN":["2641-7650"],"issn-type":[{"value":"2641-7650","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,15]]},"assertion":[{"value":"2026-03-04","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-05-02","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}