Risk of Euglycemic Diabetic Ketoacidosis Can Persist After Discontinuation of Sodium-glucose Cotransporter-2 Inhibitors

Euglycemic diabetic ketoacidosis (EDKA) is a complication of diabetes often associated with prolonged fasting, pregnancy, and, more recently, the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We present a 69-year-old woman with EDKA in the setting of cardiac surgery for multivessel coronary artery disease even after the SGLT-2 inhibitor was discontinued 5 days prior to the surgery. Postoperative lab values revealed concern for EDKA due to low bicarbonate, elevated anion gap, elevated β-hydroxybutyrate, and normal blood glucose levels. IV insulin and dextrose were administered to resolve the acidosis, but the anion gap again became elevated once the insulin infusion was stopped. We observed persistence of ketonemia and urinary glucose excretion postoperatively. This case implies that patients on SGLT2 inhibitors may be at risk for EDKA for a prolonged period even after discontinuing the medication for the recommended time before a major surgery.