Euglycemic diabetic ketoacidosis in type 2-diabetes mellitus treated with SGLT2 inhibitors - a report on two cases

Abstract

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new second-line medication in themanagement of hyperglycemia in type 2 diabetes. These drugs can be associated with thedevelopment of diabetic ketoacidosis (DKA) with normal or moderately increased blood glucoselevels. This is a life-threatening clinical condition termed euglycemic DKA, of which the diagnosiscan be delayed due to the relative euglycemia. We report on two patients with type 2 diabetes whopresented to the Emergency Department with malaise, nausea and vomiting. Both patients had beentaking dapagliflozin for at least six months. A risk factor for the development of ketoacidosis,namely heavy alcohol consumption, was found in one of the patients. Arterial blood gas analysisshowed severe metabolic acidosis with increased anion gap, positive serum and urine ketones andnormal arterial lactate. The patients were treated in Internal Medicine with intravenous fluids,insulin, sodium bicarbonate and potassium. Dapagliflozin was stopped. Both patients recovereduneventfully. Even in the absence of significant hyperglycemia, accurate interpretation of arterialblood gas analysis and serum ketones should lead to correct diagnosis of euDKA.