Abstract
BackgroundDiabetic ketoacidosis (DKA) is seen relatively frequently in the emergency department (ED). DKA is characterized by hyperglycemia, acidosis, and ketonemia, and sodium glucose transporter 2 inhibitors (SGLT2i) represent a new diabetes medication that has been associated with euglycemic DKA (eu-DKA).Case presentationA 71-year-old female who was being treated for type 2 diabetes with canagliflozin, metformin, and saxagliptin orally presented to the ED for evaluation of reduced oral intake, malaise, nausea, and abdominal pain. Although her blood glucose was not severely elevated (259 mg/dL), there was notable ketoacidosis (pH 6.89; CO2, 11.4 mmHg; HCO3, 1.9 mEq/L; base excess, − 31.3 mmol/L; 3-hydroxybutyric acid > 10,000 μmol/L) was observed. The uncontrolled acidosis improved following 3 days of continuous renal replacement therapy, but elevated urinary glucose continued for more than 10 days. Ringer’s lactated fluid supplementation was continued for management of polyurea and glucosuria. Urinary glucose turned negative on day 16, and there was improvement in the patient’s overall state; hence, she was discharged on day 18.ConclusionAlthough it is difficult to diagnose eu-DKA because of the absence of substantial blood glucose abnormalities in the ED, there is a need to consider eu-DKA when evaluating acidosis in a patient treated with SGLT2i. Moreover, even after discontinuing the SGLT2i, attention should be given to the possibility of continuing glucosuria. Regular measurements of urinary glucose should be obtained, and the patient should be monitored for dehydration.
Highlights
Diabetic ketoacidosis (DKA) is seen relatively frequently in the emergency department (ED)
We present a case of euglycemic DKA (eu-DKA) in a diabetic patient being treated with sodium glucose transporter 2 inhibitors (SGLT2i) who was monitored by blood ketone levels, daily urinary glucose, and urine volume measurements with a favorable outcome
The day prior to her ED visit, her malaise worsened, and she developed nausea and abdominal pain. She consulted a local doctor where it was discovered that she had notable metabolic acidosis; she was urgently transferred to our facility
Summary
It is difficult to diagnose eu-DKA because of the absence of substantial blood glucose abnormalities in the ED, there is a need to consider eu-DKA when evaluating acidosis in a patient treated with SGLT2i. Even after discontinuing the SGLT2i, attention should be given to the possibility of continuing glucosuria. Regular measurements of urinary glucose should be obtained, and the patient should be monitored for dehydration
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