EUDKA IN CRITICAL CARE: CASE SERIES AND LITERATURE REVIEW
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Abstract
Background: Diabetic ketoacidosis (DKA) is a serious acute medical emergency characterized by the triad of hyperglycemia, ketosis, and metabolic acidosis. However, an atypical form—euglycemic DKA—may occur with normal or only mildly elevated plasma glucose levels, leading to missed or delayed diagnosis, especially in the context of sodium-glucose cotransporter-2 (SGLT2) inhibitor use.
Objective: To describe the clinical and laboratory features of two cases of euglycemic DKA and analyze associated factors through a literature review.
Case reports: Case 1: A 50-year-old man with type 2 diabetes, recently started on empagliflozin (Jardiance) one week prior to admission. He presented with persistent vomiting and severe metabolic acidosis with a blood glucose level of 10.2 mmol/L. His condition resolved completely after 24 hours of intensive treatment.
Case 2: A 75-year-old woman with a history of hypertension and diabetes, admitted for acute myocardial infarction. During hospitalization, she received dapagliflozin (Forxiga) and subsequently developed ketoacidosis with normal or mildly elevated glucose levels. She responded well after 4 days of treatment and was transferred to cardiology care.
Discussion: Euglycemic DKA presents a diagnostic challenge due to the absence of marked hyperglycemia. Approximately 2.6–3.2% of hospitalized DKA cases have normal glucose levels. Common risk factors include SGLT2 inhibitor use, infection, prolonged fasting, and acute illness. The incidence of DKA associated with SGLT2 inhibitors ranges from 0.16 to 0.76 per 1,000 patients with type 2 diabetes. Blau et al. estimated that SGLT2 inhibitors increase the risk of DKA in type 2 diabetes patients by about sevenfold. Early recognition of high anion gap metabolic acidosis in diabetic patients, even without significant hyperglycemia, is crucial for timely diagnosis and management.
Conclusion: Euglycemic DKA is a dangerous and often under-recognized condition. Increased clinical awareness, particularly in patients using SGLT2 inhibitors, is essential for early diagnosis and improved outcomes.
Keywords
DKA, EuDKA, SGLT2 inhibitors
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References
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