SGLT2-inhibitor-induced diabetic ketoacidosis

Euglycemic diabetic ketoacidosis represents a special case of diabetic ketoacidosis characterized by metabolic acidosis and ketonemia, but only mild hyperglycemia (blood glucose levels <200-300 mg/dl or oder 11,1-16,7 mmol/l). Oral antidiabetic agents of the SGLT2-inhibitors (sodium-glucose-cotransporter type 2) type have recently gained therapeutic impact due to increasing evidence for their renal and cardiovascular benefits in addition to antihyperglycemic action. However, a particularity of SGLT2-inhibitor use is the inherent risk of patients developing EDKA with a lack of severe ketonuria, which is due to the mechanism of action of these substances. The lack of both marked hyperglycemia and ketonuria presents a diagnostic challenge often leading to delayed diagnosis and therapy in SGLT2-inhibitor-induced EDKA. Therefore, every physician in patient care has to be aware of this subform of EDKA in order to prompt diagnostic workup and immediate therapy in patients at risk. Moreover, patients on SGLT2-inhibitor therapy need appropriate education concerning the specific risks of this medication in order to prevent further episodes of EDKA.