SAT-214 Silent Danger: Euglycemic Diabetic Ketoacidosis in the shadow of SGLT2 inhibitors

Abstract C.E. Guillen Lopez: None. S. Mahesh: None. L. Sanchez Ato: None. M. Allam: None. C. Arima: None. T. Ayub: None. A. Arce Gastelum: None. Diabetic ketoacidosis (DKA) is a severe complication of diabetes characterized by a triad of hyperglycemia, anion gap metabolic acidosis, and ketosis. Euglycemic DKA (eu-DKA) was first described in 1973 and is a DKA variant with blood glucose levels below 200 mg/dl. Eu-DKA is associated with pregnancy, caloric restriction, alcohol consumption, pancreatitis, liver disease, and glycogen storage disorders. The advent of sodium-glucose cotransporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, empagliflozin) has added a potential trigger for eu-DKA, with a sevenfold increased risk in type 2 diabetes patients (T2DM) and an estimated incidence of 0.1%. SGLT2 inhibitors block glucose and sodium reabsorption in the kidney's proximal tubule, enhance urinary glucose excretion, and induce volume depletion through osmotic diuresis. Eu-DKA pathophysiology involves a carbohydrate deficit, promoting lipolysis and ketogenesis, leading to ketoacidosis while maintaining normoglycemia. Contributing factors may include reduced hepatic glucose production during fasting when glycogen stores are depleted and increased urinary glucose excretion associated with the SGLT2 inhibitors mechanism. The case of a 44-year-old patient with a history of hypertension, hyperlipidemia, morbid obesity, and type 2 diabetes mellitus on Empaglifozlin, Glipizide, and Metformin. The patient was admitted due to lung-source sepsis and high anion gap metabolic acidosis and was treated with antibiotics. Initial glucose 229 mg/dl. Posteriorly, the patient developed compensating respiratory alkalosis. Further workup showed a worsening pH of 7.19, anion gap of 27, and HCO3 of 6 mEq/L. In addition, elevated beta-hydroxybutyrate and urine ketosis were found, indicating progressive ketoacidosis despite maintaining glucose levels at 150-200 mg/dl. This was a case of delayed diagnosis of eu-DKA secondary to SGLT2 inhibitors use due to the initial picture of pneumonia. The patient was treated with insulin drip protocol until ketosis resolved. The importance of recognizing eu-DKA, especially in patients on SGLT2 inhibitors, is emphasized by its potential to be overlooked due to mild hyperglycemia or normoglycemia, leading to delayed diagnosis and treatment and potentially harmful outcomes. Addressing eu-DKA requires enhanced awareness among patients and healthcare providers, emphasizing risk factors and possible triggers, such as SGLT2 inhibitors. Staff and patient education are crucial to prompt early recognition and intervention, preventing complications, and promoting optimal management. The presented case underscores the need for vigilance in monitoring patients on SGLT2 inhibitors, particularly those with additional risk factors, contributing to a more comprehensive approach to diabetes care and avoiding potential challenges linked to eu-DKA. Saturday, June 1, 2024