Euglycemic ketoacidosis in a nondiabetic patient receiving dapagliflozin for heart failure

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are increasingly used for cardiovascular indications in patients without diabetes, increasing exposure to uncommon metabolic complications. Euglycemic ketoacidosis is a serious but under-recognized adverse effect that may be overlooked because marked hyperglycemia is absent. We report a 72-year-old woman without diabetes who presented with high anion gap metabolic acidosis: bicarbonate 16 mmol/L (reference range, 22-29 mmol/L), anion gap 19 mmol/L (reference range, 8-12 mmol/L), and glucose 140 mg/dL (7.8 mmol/L) (reference range, 70-100 mg/dL [3.9-5.6 mmol/L]). Serum beta-hydroxybutyrate was 3.4 mmol/L (reference range, <0.5 mmol/L), confirming ketosis. She was receiving dapagliflozin for heart failure. Discontinuation of dapagliflozin, intravenous fluids, and oral carbohydrate supplementation resulted in rapid resolution without insulin therapy. Because no alternative precipitant was identified and recurrence remained a concern, dapagliflozin was permanently discontinued, and SGLT2 inhibitor rechallenge was not recommended. This case demonstrates that euglycemic ketoacidosis may occur in nondiabetic patients without typical precipitants. Early recognition and individualized management can prevent unnecessary escalation of care as SGLT2 inhibitor use expands.