Empagliflozin-associated euglycemic ketoacidosis

We present a case of euglycemic ketoacidosis in a 69-year-old patient with diabetes mellitus type 2 treated with insulin and empagliflozin who was hospitalised for high-intermediate risk pulmonary thromboembolism. After initial clinical improvement with conservative therapy, on the fifth day of hospitalisation the patient became dyspnoeic (Kussmaul type), with nausea and fatigue, but without other significant physical, electrocardiographic or echocardiographic findings. Laboratory results revealed metabolic acidosis with increased anion gap and significant ketonuria, but without marked hyperglycemia. We suspected the occurrence of euglycemic ketoacidosis, stopped empagliflozin and proceeded with treatment protocol for diabetic ketoacidosis. After 36 hours the patient was stabilised with normal acid-base status, but glycosuria was observed the following seven days, as a prolonged effect of empagliflozin.