What does this research mean for the field?

In patients on SGLT-2 inhibitors presenting with severe metabolic acidosis, early measurement of serum beta-hydroxybutyrate is crucial to diagnose euglycemic diabetic ketoacidosis and avoid unnecessary invasive interventions like hemodialysis. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This study investigates the incidence of euglycemic diabetic ketoacidosis (DKA) in patients using SGLT-2 inhibitors and the implications for management.

May 20, 2026

A51-38 When the Sugar Lies: Euglycemic DKA Exposed

Key Points

This study investigates the incidence of euglycemic diabetic ketoacidosis (DKA) in patients using SGLT-2 inhibitors and the implications for management.
Single case report of a 75-year-old female with type 2 diabetes and chronic kidney disease on Jardiance.
Assessment of laboratory findings including arterial blood gases, creatinine levels, and beta hydroxybutyrate levels.
Management involved urgent hemodialysis and insulin treatment for euglycemic DKA.
The patient presented with severe metabolic acidosis (pH 6.92, bicarbonate 5meq/L).
Post-treatment normalization of the anion gap and improved clinical status were achieved.
Early ketone measurement could have reduced invasive procedures, highlighting the need for vigilant monitoring.

Abstract

Abstract Introduction SGLT-2 inhibitors have risen in popularity due to their multivariate benefits on mortality in cardiovascular and renal disease. Along with their increased use, there has been a surge in cases of euglycemic diabetic ketoacidosis (EDKA), which presents with anion gap metabolic acidosis and normoglycemia. This lack of specific symptoms often results in a missed diagnosis, potentially leading to a delay in timely management. Description A 75-year-old female with type 2 diabetes and chronic kidney disease on Jardiance presented with generalized weakness and confusion. On initial investigations, she was found to have a profound anion gap metabolic acidosis with a pH of 6.92, pCO2 of 15mmHg, serum bicarbonate of 5meq/L, and an anion gap of 32. Other significant laboratory findings included a creatinine of 5.0, BUN of 98 and a normal serum lactate, glucose and osmolar gap. Furthermore, urinalysis was negative for ketones. The patient underwent urgent dialysis catheter placement and subsequent hemodialysis, resulting in some improvement in her mental status and blood gas. However, beta hydroxybutyrate levels measured a few hours after admission were significantly elevated. She was treated with insulin and IV fluids for euglycemic diabetic ketoacidosis, resulting in resolution of her anion gap and improvement in clinical status. Discussion Severe SGLT-2 inhibitor-associated euglycemic DKA is classified as a pH 7.0 or serum bicarbonate10meq/L. Although medically resistant metabolic acidosis is an indication of hemodialysis, the management of euglycemic DKA hinges on insulin rather than solute clearance, as it corrects the underlying acidosis, closes the anion gap and improves acid-base status. This case highlights the importance of early ketone measurement and medication reconciliation, which may have avoided the need for invasive procedures, allowed conservation of valuable ICU resources. These measures could lead to reduced patient morbidity and iatrogenic complications, and hence improved outcomes. This abstract is funded by: None

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