Relapse of Euglycemic Diabetic Ketoacidosis With Prolonged Glucosuria and Ketonuria Associated With Pre-operative Sodium-Glucose Co-transporters 2 (SGLT-2) Inhibitor Use

Sodium-glucose co-transporters 2 (SGLT2) inhibitors are an important class of medications that have become increasingly used not only in the management of type 2 diabetes but also for cardioprotection and slowing the progression of renal dysfunction. However, clinicians should be aware of the risk of euglycemic diabetic ketoacidosis associated with their use, particularly in cases of severe illness, volume depletion, decreased carbohydrate intake, or recent surgery. We present a case of a 68-year-old male, whose type 2 diabetes mellitus was controlled with dapagliflozin 10 mg daily, and was electively admitted for left tibial fracture surgery. He continued to take dapagliflozin until one day prior to the scheduled surgery date and was discharged home the day after the procedure. Twelve hours after discharge, he presented again to the emergency room with severe euglycemic diabetic ketoacidosis (EuDKA) and acute kidney injury (AKI), which required intensive care admission and initiation of the diabetic ketoacidosis (DKA) protocol. Despite successful treatment of EuDKA and AKI, and subsequent transfer to the medical floor, his urinalysis showed persistent ketonuria and glucosuria, even though blood sugar readings remained below the renal threshold of glucosuria. On the medical floor, euglycemic diabetic ketoacidosis recurred eight days after the last dose of dapagliflozin. The second EuDKA episode resolved following another 24 hours of treatment with the DKA protocol. The patient's hospital stay was complicated by partial deep thrombosis of the distal superficial femoral vein (DVT), which was treated with apixaban. He was discharged in stable condition while his urinalysis was still showing persistent glucosuria and ketonuria, with near-normal serum blood glucose levels after 11 days of dapagliflozin cessation.