MON-587 SGLT2 Inhibitor-Related Starvation Ketoacidosis- a Case Series

Abstract Disclosure: J. Park: None. C. Chu: None. V.C. Hsiao: None. U. Masharani: None. E.J. Murphy: None. Introduction: As the indication for sodium-glucose co-transporter 2 inhibitors (SGLT2i) expands to heart failure and chronic kidney disease management, there have been increasing reports of euglycemic ketoacidosis in patients without clear evidence of absolute or relative insulin deficiency. The underlying pathophysiology and therapeutic approach for this medication-induced adverse effect may differ from that of classic euglycemic diabetic ketoacidosis (eDKA). Case Presentation: Herein we describe two cases of SGLT2i-related glycopenic ketoacidosis with that was successfully treated with glucose supplementation without the use of insulin. Case 1 describes a 61-year-old male on empagliflozin 10mg who experienced subacute weight loss and repeated presyncope episodes following a femoral neck fracture, ultimately found to have beta-hydroxybutyrate (BHB) levels of 5.5 and glucosuria >=500mg/dL despite a lack of a diabetes history. Anion gap was closed within 36 hours after prompt nutritional support. Case 2 describes a 77-year-old male with well-controlled type 2 diabetes mellitus on empagliflozin 25mg who presented with holohemispheric subdural hematoma. During the hospitalization, patient had two episodes of ketoacidosis accompanied with serum glucoses less than 120mg/dl-- both of which were below the threshold for insulin drip initiation based on hospital protocol. During both episodes, the patient’s ketoacidosis improved with glucose supplementation and minimal fluid resuscitation. SUMMARY: SGLT2i may cause glycopenic ketoacidosis more akin to starvation ketosis. The cases were characterized by modest ketosis and borderline hypoglycemia that resolves spontaneously with nutrition rather than treatment with insulin. It may prove useful for clinicians to distinguish between the glycopenic and insulinopenic varieties of SGLT2i-related ketoacidosis in order to avoid unnecessary intensive care-level treatment. Presentation: Monday, July 14, 2025