# A Case of BRASH (Bradycardia, Renal Dysfunction, Atrioventricular Node Blockade, Shock, and Hyperkalemia) Syndrome Following Initiation of a Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitor and a Loop Diuretic

## TL;DR

This paper reports a case of BRASH syndrome in a patient after starting a new medication, highlighting the importance of monitoring kidney function and managing diuretics carefully.

## Contribution

The paper presents a novel case linking dapagliflozin, an SGLT-2 inhibitor, to BRASH syndrome, which had not been previously documented.

## Key findings

- BRASH syndrome occurred in a 73-year-old patient after starting dapagliflozin and a loop diuretic.
- The case highlights the need for clinicians to monitor renal function and manage diuretics carefully in patients with comorbidities.
- Educating patients on volume management and diuretic use is emphasized to prevent complications.

## Abstract

BRASH (bradycardia, renal dysfunction, atrioventricular node blockade, shock, and hyperkalemia) syndrome is a recently recognized clinical process that can be fatal if not adequately and promptly treated. As such, it is important for clinicians to recognize the syndrome. This case demonstrates an example of BRASH syndrome in a 73-year-old patient with heart failure occurring after initiation of dapagliflozin, a drug not previously associated with this phenomenon in the literature. Given the increasingly appreciated clinical utility of sodium-glucose cotransporter-2 (SGLT-2) inhibitors, prescribers must respect their potential side effects in patients with underlying comorbidities and remember the importance of re-evaluating renal function after initiation of these medications. Here, we review the pathophysiology of BRASH, the renal effects of SGLT-2 inhibitors, and the importance of educating patients on volume management and diuretic dose titration at home.