Euglycemic Ketoacidosis Secondary Due to SGLT2 Inhibitors

Abstract

Euglycemic diabetic ketoacidosis (EDKA) is an uncommon diabetic complication associated with several risk factors such as fasting, surgery, pregnancy, and now the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. EDKA is primarily related to an imbalance between insulin and counter-regulatory hormones, with an elevated glucagon/insulin ratio. EDKA can lead to serious complications, including significant dehydration, if not recognized early and treated appropriately with fluids, dextrose, and insulin. In the context of normal blood glucose levels, it is characterized by an increased anion gap metabolic acidosis with ketonemia/ketonuria. Pregnancy, extended fasting, and bariatric surgery are common risk factors for the development of this illness. As a sporadic cause of euDKA, sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been discovered. Euglycemic diabetic ketoacidosis (DKA, EDKA) is a clinical syndrome occurring both in type 1 (T1DM) and type 2 (T2DM) diabetes mellitus characterized by euglycemia (blood glucose less than 250 mg/dL) in the presence of severe metabolic acidosis (arterial pH less than 7.3, serum bicarbonate less than 18 mEq/L) and ketonemia. A recent literature review found only 77 case reports of euDKA secondary to SGLT-inhibitors published in the medical literature up to 02 August, 2020.
Here, we present the case of a 43-year-old man who was taking empagliflozin, an SGLT-2 inhibitor. The patient was found to have euDKA, which was likely an adverse effect of his medication.