Postoperative Euglycemic Ketoacidosis in Type 2 Diabetes Associated with Sodium-Glucose Cotransporter 2 Inhibitor: Insights Into Pathogenesis and Management Strategy

Euglycemic diabetic ketoacidosis (eu-DKA) is an uncommon and serious adverse event associated with the use of sodium-glucose cotransporter (SGLT-2) inhibitors. It is a state of increased anion gap metabolic acidosis with ketosis but in the setting of normal serum glucose levels. Diagnosis of this serious entity could easily be missed given the non-specific symptoms and the normal glucose measurements. This ketogenic state can be triggered by various stressors including infection, surgery, myocardial infarctions, omission of insulin dosage, as well as low carbohydrate diet. In this report, we present a case of eu-DKA in a 68-year-old woman with type 2 diabetes that occurred in the postoperative period of glaucoma surgery. She was started shortly before surgery on SGLT-2 inhibitor (ertugliflozin). While the diagnosis was initially missed, it was subsequently confirmed when she presented with reduced appetite, generalized fatigue, and constipation. Ertugliflozin was discontinued, and she was successfully treated with conservative management and without insulin drip. This case highlights the need to consider the diagnosis of eu-DKA in patients treated with SGLT-2 inhibitors since the diagnosis could easily be missed especially in the postoperative period with the non-characteristic symptomatology and normoglycemia.