SGLT2 Inhibitor–Induced Euglycemic Diabetic Ketoacidosis: A Case Report

Abstract

Introduction: Euglycemic diabetic ketoacidosis (EuDKA) is a rare but serious complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We present a case of a 39 year old patient with EuDKA precipitated by empagliflozin therapy. Case report: Male patient with a history of type 2 diabetes for 7 years, on metformin, vildagliptin, gliclazide and multiple sclerosis for 2 years, on biological therapy, was treated with high doses of corticosteroids due to progression of neurological symptomatology. Because of poorly controlled diabetes with HbA1c of 12.1%, 10mg of empagliflozin was instituted in outpatient conditions. Seven days after the initiation of empagliflozin, patient presented to the emergency department with complaints of malaise, abdominal discomfort, loss of appetite and muscle cramps. Laboratory analysis showed glycaemia of 8,1 mmol/l, normal blood urea, creatinine, electrolytes and high levels of ketone in urine. Patient was treated with 0,9% solution of NaCl, 40mg of pantoprazole and discharged. Several hours later due to worsening of the condition patient was admitted to the intensive care unit. On admission glycaemia was 8,1 mmol/l, heart rate 130/min, arterial tension-127/66 mmHg, oxygen saturation 87%, arterial blood gases pH- 6.87, pO2- 177mmHg, pCO2- 7 mmol/l, bicarbonate-3,0 mmol/l, potassium-3,8 mmol/l, lactate-2,8 mmol/l. Therapy with intensive fluid replacement, intravenous insulin infusion, potassium chloride, bicarbonate and noradrenalin was instituted and mechanical ventilation was indicated. After patient condition gradually improved, transition to subcutaneous insulin therapy was made. Conclusion: Early identification of diabetic ketoacidosis despite euglycemia is essential for timely institution of treatment. Avoiding initiation of SGLT-2 inhibitors in volume-depleting illnesses, diminished oral intake, infection or other metabolic stressors reduces the risk for ЕuDKA .