SGLT2 inhibitor-induced ketoacidosis – A diagnostic challenge

Diabetic ketoacidosis is rarely caused by sodium-glucose cotransporter-2 (SGLT2) inhibitors and can be difficult to recognize. A 56-year-old male patient, with a body mass index of 31.87 and a long-standing history of diabetes mellitus, presented with acute gangrenous cholecystitis and was treated with intravenous antibiotics. Empagliflozin and metformin were started for blood sugar control. Four days after surgery, he presented with nausea and vomiting. He was found to have deep and labored breathing following upper gastrointestinal endoscopy. Labs revealed severe ketoacidosis with normal blood sugars. He was hydrated well with no improvement in metabolic acidosis. Empagliflozin was stopped, intravenous insulin and dextrose infusions were started, and his acidosis was corrected rapidly. SGLT2 inhibitors are associated with an increased risk of diabetic ketoacidosis (DKA). The absence of substantial hyperglycemia potentially delays the diagnosis. The stress of recent surgery likely precipitated DKA in this patient. It is important to consider the diagnosis of euglycemic DKA in patients receiving empagliflozin and presenting with nausea and vomiting, especially in the immediate postoperative period.