Case of Euglycemic Diabetic Ketoacidosis due to SGLT2 inhibitor Empagliflozin

Diabetes is a global pandemic. sodium-glucose cotransporter 2 (SGLT2) inhibitors are the common medicinal management for diabetes. Empagliflozin which is a SGLT2i is frequently prescribed for diabetes due to its cardiorenal advantages. Diabetic ketoacidosis (DKA) is one of the most serious, significant, and acute diabetic complications characterized by hyperglycemia and ketoacidosis.

Euglycemic DKA (EDKA) keeps the patient’s serum glucose concentration within the normal range posing difficulty for the physician and the patient to identify it immediately. Previous literature shows that EDKA is one of the complications of using Empagliflozin. Waleed M. Altowayan from Qassim University, Saudi Arabia presents a case report of EDKA in a patient due to the use of 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.

It is necessary for both healthcare professionals and patients to be aware of the symptoms of EDKA like nausea, vomiting, fatigue, and dehydration. In such situations, it is advisable to get the ketone levels assessed and discontinue the SGLT2i if suspicion of the development of ketoacidosis is suspected.

The author further emphasizes that euglycemia is a common feature and can cause delays in the diagnosis. Hence, EDKA should always be considered in individuals who are on SGLT2i and developing unexplained metabolic acidosis.