MON-648 A Deadly Duo: Rapid-Onset Lactic Acidosis and Euglycemic DKA in a Young Male with Normal Renal Function on Metformin and Empagliflozin Resumption

Abstract Disclosure: S.C. Macapagal: None. C.C. Park: None. K. Wirunsawanya: None. We report the first case of a young male with type 2 diabetes mellitus and normal kidney function who presented with combined lactic acidosis and euglycemic diabetic ketoacidosis (euDKA) after the resumption of metformin and empagliflozin. This is a rare presentation, with only a limited number of documented data. According to published case reports, it is typically observed in the setting of acute kidney injury, advanced age, and significant co-morbidities. A 36-year-old diabetic male with non-insulin-dependent diabetes mellitus type 2, dyslipidemia, and prior pancreatitis in 2020 who presented to the emergency department with complaints of nausea, vomiting, and abdominal pain. He had been using empagliflozin and metformin for the past six years, but discontinued both medications two months ago due to financial constraints in transportation that hindered his ability to acquire them. He had poor glycemic control reflected by his HbA1c of 12.4% due to medication non-adherence. When he had the chance to get the medications, he took the metformin 1000 mg followed by another dose in four hours (total: 2,000mg) with a one-time dose of empagliflozin 25 mg. After four hours, he woke up with nausea, vomiting, chills, confusion, and fatigue. Initial investigations showed high anion gap metabolic acidosis (bicarbonate of 10 mEq/L with a gap of 33), ketosis (beta-hydroxybutyrate > 9.00 mmol/L), hyperlactemia (3.2 mEq/L), and hyperkalemia (7.0 mEq/L). He did not have an acute kidney injury. His creatinine and eGFR were 1.0 mg/dL and 100 ml/min/1.73, respectively. He was found to have combined lactic acidosis and euDKA. His home diabetic medications were stopped and he was treated with intravenous fluids and insulin infusion with improvement of symptoms. His blood glucose levels have never exceeded 250 mg/dL throughout the admission. His metabolic derangements and symptoms were resolved following treatment. On discharge, he was started on a short and long-acting insulin regimen. This case emphasized that metformin and empagliflozin resumption can present with an unusual combination of lactic acidosis and euDKA even in a young diabetic male without significant renal impairment and co-morbidities. SGLT2 inhibitors are recognized for causing euDKA, their correlation with lactic acidosis has been rarely documented. Therefore, lactic acidosis and hyperkalemia were probably attributable to metformin use. Clinicians should be aware of this atypical presentation, as early recognition and prompt management are crucial in improving the outcome of such cases. Presentation: Monday, July 14, 2025