A Case of Severe Metabolic Acidosis due to Jardiance-Induced Euglycemic Diabetic Ketoacidosis

Metabolic acidosis is frequently encountered in the inpatient setting. It can occur due to either the accumulation of endogenous acids that consumes bicarbonate (high anion gap metabolic acidosis) or loss of bicarbonate from the gastrointestinal tract or the kidney. Jardiance® (empagliflozin) (Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, USA) is a sodium-glucose co-transporter 2 (SGLT2) inhibitor, which reduces renal tubular glucose reabsorption, thereby decreasing blood glucose level without stimulating insulin release. This class of drugs is known for reducing cardiovascular events and delay in the progression of chronic kidney disease in patients with type 2 diabetes mellitus (T2DM). However recent data has shown that SGLT2 inhibitors, particularly empagliflozin, carry the risk of inducing euglycemic diabetic ketoacidosis under certain circumstances such as acute illness, and decreased carbohydrate intake, decrease in dose, or discontinuation of insulin. We herein report a 23-year-old female with poorly controlled diabetes mellitus on empagliflozin, who presented with dyspnea and coronavirus disease SARS-CoV-2 (COVID-19) infection and found to have severe unexplained euglycemic metabolic acidosis, with elevated urine ketones.