Case of Euglycemic Diabetic Ketoacidosis due to SGLT2 inhibitor Empagliflozin

A 75-year-old woman with a 15-year history of type 2 diabetes mellitus presented to the emergency department with decreased consciousness and decreased oral intake for two days. She had been diagnosed with a cerebrovascular accident 12 days back and was discharged then with drugs like empagliflozin, aspirin, and atorvastatin.

There were no preceding symptoms, moderately dehydrated, with dry oral mucosa and poor skin turgor. CT scan and blood investigations were unremarkable except for metabolic acidosis, despite a minimally elevated serum glucose concentration. The patient was admitted to the intensive care unit with a diagnosis of EDKA secondary to empagliflozin and treated with intravenous rehydration therapy and intravenous insulin infusion. The patient was later discharged after gradual resolution of the ketoacidosis, with a normalized anion gap and elimination of the serum ketones,and was prescribed metformin extended release of 1 g daily and insulin 70/30 (20 U) twice daily.

This case emphasizes the importance of being aware of the development of EDKA in diabetics with the use of SGLT2i. SGLT2i promotes excretion and blocks glucose reabsorption from the proximal convoluted tubule causing carbohydrate starvation and volume depletion leading to a state of severe dehydration and ketosis due to an increased glucagon/insulin ratio. Apart from this mechanism they also enhance the release of glucagon from the pancreas, which worsens the existing glucagon/insulin imbalance.