Recognizing Euglycemic Diabetic Ketoacidosis in the Era of SGLT2 Inhibitors: A Case Report

Euglycemic diabetic ketoacidosis (euDKA) is an increasingly recognized complication associated with SGLT2 inhibitors. Because serum glucose levels may remain normal or only mildly elevated, diagnosis can be delayed, potentially increasing morbidity. We present the case of a 51-year-old male with long-standing poorly controlled type 2 diabetes mellitus who developed euDKA shortly after initiation of empagliflozin/metformin therapy. The patient presented with generalized weakness, gastrointestinal symptoms, reduced oral intake, polyuria, polydipsia, and weight loss. Initial laboratory evaluation revealed high anion gap metabolic acidosis with positive urinary ketones and a glucose level of 160 mg/dL. Infectious workup was negative. The patient required intensive care management with intravenous fluids, insulin infusion, electrolyte monitoring, and dextrose-containing fluids, with subsequent complete resolution of metabolic abnormalities. This case adds to the growing body of literature describing euDKA in patients receiving SGLT2 inhibitor therapy in the setting of reduced oral intake and poorly controlled diabetes mellitus.