A Case of SGLT-2i Induced Euglycemic Diabetic Ketoacidosis in the Setting of Gastrointestinal Stress

Abstract

Euglycemic DKA (euDKA) is a rare, uncommon variant of DKA, characterized by the imbalance between insulin and counterregulatory hormones. Lately, the use of SGLT2 inhibitors is known to incite euDKA, which is often missed on initial presentation. In this case, we present a scenario of a 61-year-old African American male with a history of hypertension, CAD s/p CABG, and type 2 diabetes mellitus on SGLT2i (empagliflozin) with a clinical picture of normoglycemic DKA process. With a pH of 7.14, bicarbonate of 8 mEq/L, anion gap (AG) of 17mEq/L, ketoacidosis, and glucosuria, the patient met criteria for euDKA; however, the initial clinical diagnosis of euDKA was overlooked by the possibility of an underlying infectious gastroenteritis, given his recent history of travel with passengers with similar presentation, causing a delay in euDKA management. The management of euDKA is like that of a typical DKA, inculcating aggressive fluid resuscitation and insulin, followed by a permanent discontinuation of SGLT2i. Thus, this case highlights the importance of understanding SGLT2i induced euDKA and its early diagnostic and timely management to prevent further complications.