Self-Induced Euglycemic Diabetic Ketoacidosis: When to Stop the Drip

Area of Science:

• Endocrinology
• Pharmacology

Background:

• Diabetic ketoacidosis (DKA) is a severe complication of diabetes mellitus.
• Sodium-glucose cotransporter 2 (SGLT-2) inhibitors offer cardiovascular and renal benefits but are associated with euglycemic DKA.
• Euglycemic DKA presents a diagnostic challenge due to normal blood glucose levels.

Observation:

• A 56-year-old male with type 2 diabetes, treated with metformin and empagliflozin/linagliptin, presented with a diabetic foot ulcer.
• Despite refusing insulin, he continued home medications, leading to metabolic derangements indicative of DKA.
• The patient developed DKA with a serum glucose of 141 mg/dL, high beta-hydroxybutyrate, and anion gap metabolic acidosis.

Findings:

• The patient was diagnosed with euglycemic DKA, characterized by ketoacidosis despite normal glucose levels.
• Treatment involved an insulin drip, dextrose, and saline, followed by subcutaneous insulin upon resolution.
• Discharge instructions included avoiding SGLT-2 inhibitors.

Implications:

• This case underscores the need for vigilance in diagnosing and managing euglycemic DKA, particularly in patients using SGLT-2 inhibitors.
• Lack of specific guidelines necessitates careful monitoring for this potentially overlooked complication.
• Increased use of SGLT-2 inhibitors requires heightened awareness of their associated risks and contraindications.