Perioperative Euglycemic Ketoacidosis Despite Discontinuation of Sglt2 Inhibitors: A Review of Reported Cases

Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are increasingly used in the treatment of type 2 diabetes mellitus, heart failure, and chronic kidney disease. A rare but potentially life-threatening adverse effect is euglycemic diabetic ketoacidosis (euDKA), particularly in the perioperative setting. Aim: To analyze reported cases of perioperative euDKA occurring despite preoperative discontinuation of SGLT2 inhibitors. Material and Methods: A literature review of PubMed publications from February 2020 to January 2026 was conducted. Case reports and case series describing perioperative euDKA after prior discontinuation of SGLT2 inhibitors were included. Results: Eight cases met the inclusion criteria. The duration of drug withdrawal ranged from 18 hours to 5 days before surgery. euDKA developed intraoperatively or in the early postoperative period and was characterized by high anion gap metabolic acidosis with normal or mildly elevated glucose levels. Six patients recovered, whereas two patients died. Conclusions: Perioperative euDKA may occur despite adherence to current discontinuation guidelines. Ketone monitoring and heightened clinical vigilance are essential throughout the perioperative period.