Euglycemic diabetic ketoacidosis after the initiation of dulaglutide in patient with type 2 diabetes

RATIONALE: Diabetic ketoacidosis is rarely observed when the blood glucose level is <250 mg/dL. This is referred to as euglycemic diabetic ketoacidosis (EDKA). EDKA can present diagnostic and management challenges for physicians, especially when dealing with unusual triggers such as glucagon-like peptide 1 (GLP1) receptor agonists and sodium-glucose co-transporter 2 inhibitors. With this case report, we wanted to raise the knowledge and understanding of EDKA and its triggering factors. PATIENT CONCERNS: A 45-year-old man was admitted to hospital for epigastric pain, loss of appetite, and vomiting 3 days after the initiation of dulaglutide. The results of laboratory examination showed EDKA. DIAGNOSES: The patient was diagnosed with EDKA after the initiation of GLP1 receptor agonists. INTERVENTIONS: Intravenous fluid and insulin infusion were immediately started. OUTCOME: The patient was discharged after treatment. LESSONS: In this case report describes the use of GLP1 receptor agonists along with Sodium-glucose co-transporter 2 inhibitors in type 2 diabetes patients whose extreme restriction of carbohydrate intake may have triggered EDKA. Therefore, physicians should use diabetes medications in a stepwise manner and advise their patients not to over-restrict their carbohydrate intake while they are being treated with GLP1 receptor agonists.