"Normal but Catastrophic" Euglycemic Diabetic Ketoacidosis Precipitated by Sodium-Glucose Cotransporter-2 Inhibitor Use: A Case Report

Euglycemic diabetic ketoacidosis (EuDKA) is an uncommon diabetic complication. Just like diabetic ketoacidosis (DKA), EuDKA is a medical emergency. EuDKA is primarily related to the imbalance between insulin and counter-regulatory hormones, with an elevated insulin/glucagon ratio, and is characterized by blood glucose near normal (blood glucose less than 250 mg/dL) in the background of DKA. There are many factors associated with EuDKA, but the overall mechanism is based on a relative state of carbohydrate deficit, resulting in ketosis while maintaining near-normal glucose levels. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new oral antidiabetic medication category that can precipitate EuDKA. EuDKA is more common in patients with diabetes mellitus on SGLT2 inhibitors with lower mass index and decreased glycogen store which can be triggered by surgery, infection, trauma, a major illness or reduced food intake and persistent vomiting, gastroparesis, dehydration, and reduced insulin dosages.This is a case of a 34-year-old male, Filipino, diagnosed with type 2 diabetes mellitus, who was maintained on dapagliflozin + metformin 5mg/1000mg taken twice a day with good compliance and was admitted with EuDKA precipitated by decreased food intake and managed with intravenous insulin. Throughout admission, the blood glucose levels did not exceed 250mg/dL. His clinical condition improved through insulin therapy, administration of sodium bicarbonate, and intravenous hydration. EuDKA is an uncommon diabetic complication. High clinical suspicion is required to avoid delay in diagnosis and management since normal blood sugar levels masquerade the underlying DKA. Nevertheless, the cornerstone for the management of DKA and EuDKA remains the same: intravenous hydration and insulin therapy.