Euglycemic Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: A Case Series and Clinical Reflections

Euglycemic diabetic ketoacidosis (EuDKA) is a rare but potentially life-threatening complication of sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy. It is characterized by high anion-gap metabolic acidosis and ketonemia despite near-normal blood glucose levels, which can delay recognition and treatment. Reports from low- and middle-income countries (LMICs) remain limited. This case series from an LMIC describes three patients with type 2 diabetes mellitus and multiple comorbidities, including hypertension, ischemic stroke, chronic kidney disease, and poliomyelitis developed EuDKA associated with SGLT2 inhibitor (SGLT2i) use. Despite blood glucose levels remaining below the typical diabetic ketoacidosis threshold, all patients presented with hallmark metabolic acidosis and ketonemia, posing diagnostic challenges exacerbated by overlapping acute illnesses and limited diagnostic resources. Diagnosis was based on clinical suspicion and laboratory confirmation through venous blood gas analysis, positive ketones, and high anion-gap metabolic acidosis. Management involved standard EuDKA protocols comprising intravenous fluids, insulin infusions, and electrolyte correction, which led to gradual resolution of acidosis and normalization of biochemical parameters. These cases emphasize the importance of maintaining vigilance and providing prompt treatment for EuDKA in complex clinical contexts, particularly within resource-constrained healthcare systems. All three patients developed EuDKA related to SGLT2i use during acute illness but recovered fully following prompt diagnosis and standard DKA management with fluids, insulin, and electrolyte correction. These cases emphasize that early recognition, appropriate management, and patient counseling on temporary drug cessation during intercurrent illness are vital to prevent recurrence, especially in resource-limited settings.