Life-threatening dapagliflozin-associated euglycaemic diabetic ketoacidosis in a postoperative patient

Euglyceamic diabetic ketoacidosis (EuDKA) is an uncommon but serious diabetes mellitus complication associated with risk factors such as fasting, surgery, pregnancy and, more recently, the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). This case is of a woman with type 2 diabetes and hypertension in her 50s who underwent an incarcerated umbilical hernia repair and abdominoplasty. Two days after discharge, she was readmitted with nausea, vomiting, loss of appetite, low-grade fever and breathing difficulty. Preoperatively, her diabetes management included an SGLT2i. She was diagnosed with EuDKA with high anion gap metabolic acidosis, a medical emergency similar to diabetic ketoacidosis. The normal blood glucose levels in EuDKA can mask the condition, which poses a conundrum for physicians in the emergency department/intensive care units as it may delay diagnosis and treatment, worsening the outcomes. To mitigate this risk, SGLT2i should be stopped 3-4 days before planned surgery with appropriate adjustments to the insulin regimen.