Euglycemic diabetic ketoacidosis: A missed diagnosis

Area of Science:

• Endocrinology and Metabolism
• Nephrology
• Internal Medicine

Background:

• Euglycemic diabetic ketoacidosis (DKA) presents a diagnostic challenge due to the absence of hyperglycemia, potentially delaying critical treatment.
• The incidence of euglycemic DKA is rising, particularly with the increased use of sodium/glucose cotransporter-2 (SGLT-2) inhibitors in diabetes management.
• This condition can occur in both type 1 and type 2 diabetes mellitus patients and has various other potential triggers.

Purpose of the Study:

• To highlight the diagnostic complexities and clinical considerations of euglycemic DKA.
• To discuss the pathophysiology, differential diagnosis, and management strategies for this metabolic emergency.

Main Methods:

• Review of the pathophysiology of euglycemic DKA, including carbohydrate deficit, insulin dynamics, and glucagon/insulin ratios.
• Emphasis on diagnostic workup, including arterial blood gas analysis, serum ketones, and exclusion of other causes of metabolic acidosis.
• Discussion of treatment principles mirroring standard DKA management: fluid resuscitation, electrolyte correction, and insulin therapy.

Main Results:

• Euglycemic DKA is a diagnosis of exclusion, requiring a high index of suspicion in diabetic patients presenting with metabolic acidosis.
• SGLT-2 inhibitors are a significant factor contributing to the increased incidence of this condition.
• Treatment involves aggressive management of dehydration, electrolyte imbalances, and ketonemia with insulin and dextrose-containing fluids.

Conclusions:

• Euglycemic DKA necessitates careful consideration in sick diabetic patients, even with normal glucose levels.
• Early recognition and appropriate management are crucial to prevent severe complications and improve patient outcomes.
• Understanding the role of SGLT-2 inhibitors and other triggers is key to timely diagnosis and effective treatment.