#3810 Euglycemic diabetic ketoacidosis associated with the use of sodium-glucose cotransporter 2 inhibitors: a case series

Abstract Background and Aims Diabetic ketoacidosis (DKA) is a known acute complication of diabetes mellitus (DM). It can lead to serious morbidities, and sometimes to death, if not well recognized and managed. Blood glucose is usually significantly high in patients presenting with DKA. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are one of the medications used for management of DM. They are also used to slow the progression of chronic kidney disease (CKD) in both diabetics and non-diabetics. In addition, they are used in the management of heart failure patients. Their use is also expanding for other indications. One of the major adverse effects of SGLT2i is the increased risk of developing euglycemia DKA (EuDKA), which can sometimes present a diagnostic difficulty. Here, we describe 6 patients in a single center presenting with EuDKA due to the use of SGLT2i. Method Our hospital's electronic medical record system was searched for patients who were admitted and discharged with the diagnosis of EuDKA. EuDKA was diagnosed if the patient has a blood glucose level of less than 250 mg/dl, metabolic acidosis (pH < 7.3 and serum bicarbonate < 15 mmol/l) and the presence of ketone bodies in blood or urine. Patients with EuDKA were checked to see if they were taking SGLT2i at the time of presentation. Patients’ characteristics, clinical presentations, laboratory values, management received and outcome were collected and described. Results Between 2021 and 2024, we found 6 patients (4 females and 2 males) who fulfilled the criteria of EuDKA and taking SGLT2i at the time of presentation. Their age ranged between 21 and 74 years. Nausea, vomiting, malaise, abdominal pain and altered level of consciousness were common symptoms. On presentation, blood glucose ranged between 150 and 237 mg/dl, serum bicarbonate between 6.4 and 11.6 mmol/l and anion gap between 20 and 25 mmol/l. All patients were managed by intravenous fluids and insulin infusion for their DKA, and one patient required one session of hemodialysis for resistant acidosis. All were admitted to the intensive care unit for a part of their hospital stay before their discharge home. The hospital stay ranged between 4 and 7 days. Table 1 shows the detailed characteristics and laboratory values for the patients. Conclusion EuDKA is one of the complications for the use of SGLT2i. It should be suspected in any patient who takes these medications and presents acutely ill or has metabolic acidosis. The condition can be so serious to the extent of needing dialysis to manage the metabolic consequences of the disease.