Sodium-glucose co-transporter 2 inhibitors induced euglycemic diabetic ketoacidosis within four days of initiation

Abstract

Euglycemic diabetic ketoacidosis (EDKA) is a well-known complication of sodium-glucose co-transporter 2 inhibitors, and many cases with variable onset following the initiation of these agents are reported before, with a median onset of approximately 2 wk. This letter discusses a 45-year-old lady who initially presented with ischemic stroke but developed EDKA 4 d after starting empagliflozin, a rare occurrence. The patient had severe metabolic acidosis that necessitated admission into the intensive care unit. Prompt discontinuation of empagliflozin and DKA management resulted in clinical recovery.

Keywords: Euglycemic diabetic ketoacidosis; Sodium-glucose co-transporter 2 inhibitors; Type 2 diabetes mellitus; Empagliflozin

Core Tip: With a steady surge in the prescription of sodium-glucose co-transporter 2 inhibitors (SGLT2-i) in medical conditions including type 2 diabetes mellitus (DM), type 1 DM, and heart failure, there are increasingly reported cases of euglycemic diabetic ketoacidosis (EDKA) with their use. EDKA in the context of SGLT2-i use is reported in various patients with different precipitating factors, some even with no inciting event. One of the rarely reported inciting events is stroke. Another aspect of SGLT2-i induced EDKA which remains relatively less understood is the time of initiation of the drug to the development of EDKA. In our patient, severe EDKA developed within 4 d of empagliflozin initiation, necessitating intensive care and discontinuation of empagliflozin, resulting in complete recovery regarding the EDKA.