Sodium-Glucose Linked Transporter Inhibitors as a Cause of Euglycemic Diabetic Ketoacidosis on a Background of Starvation

We present a case of a male diabetic patient with one of the most well-known major complications of diabetes mellitus (DM), i.e., diabetic ketoacidosis (DKA). The finding of euglycemic DKA, or DKA with blood glucose levels of less than 200 mg/dL, is a rare occurrence especially in patients with type II DM. He presented with hypotension and increased anion gap metabolic acidosis on a background of keto diet for weight loss and recent use of sodium-glucose linked transporter inhibitors. He was successfully managed with dextrose water, insulin infusion, and potassium replacement. A ketogenic diet consists of high fat, low carbohydrate, and adequate protein regimen that sends the body into a state of starvation in which high glucagon and low insulin levels lead to the activation of other counter-regulatory hormones, such as epinephrine and cortisol, that causes a rise in the level of free fatty acids in the blood increasing ketone body production. Rarely, sodium-glucose linked transport inhibitors can also cause DKA, with euglycemia instead of hyperglycemia. The finding of plasma glucose levels within normal range prompted patients to maintain and sometimes even lower their insulin dose; even their providers were often misled by the euglycemia that resulted in delayed diagnosis and treatment. Thus, it is imperative to stay aware of the possible clinical presentations in order to intervene in a timely manner and prevent further progression and complications.