Scientific Poster Session II - Case Reports

Abstract

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes. Euglycemic diabetic ketoacidosis (EDKA) presents a diagnostic challenge in the emergency department. EDKA is associated with risk factors like fasting, pregnancy, and alcohol use. Here, we present a case of EDKA caused by empagliflozin use in a male patient with no known risk factors

Case:

A 43-year-old male with type 2 diabetes presented to the ED with symptoms of nausea, vomiting, and weakness. He had recently started empagliflozin after previous medications failed to control his diabetes. His current treatment included empagliflozin 10 mg once daily and metformin 500 mg twice daily. His latest HbA1c was 10%. Vital signs were stable. Blood glucose was 8.7 mmol/L, while venous blood gas analysis showed severe acidosis with pH 6.9, critically low bicarbonate (HCO3) of 6 mmol/L, and normal lactate levels. Anion gap was 22, indicating high anion gap metabolic acidosis. Urine analysis revealed ketonuria (4+), proteinuria, and glucosuria. Diagnosis of EDKA was confirmed, and the patient was successfully treated and discharged.

Discussion:

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been associated with EDKA, especially with increased global use. EDKA can be precipitated by factors like pregnancy, surgery, missed insulin doses, alcohol consumption, or decreased carbohydrate intake. In this case, no risk factors were identified other than empagliflozin initiation. SGLT2i affect glucose excretion and ketone reabsorption in the kidneys. They may also inhibit beta cells, increasing lipolysis and ketone production. Additionally, SGLT2i stimulate pancreatic alpha cells, leading to glucagon release, further promoting lipolysis and ketogenesis.

Conclusion:

Diagnosing SGLT2i-induced EDKA is challenging due to normal or slightly elevated blood glucose levels. Obtaining a detailed medication history by clinical pharmacist in ED is crucial. Patients should be educated about risk factors, triggers, and symptoms. Further research is needed to understand the mechanisms of EDKA in various precipitating events.

Presenting Author

Authors