Authors: Abdullah M. Alzahrani , Ghaida I Alselami , Manal Naser Almutairy , Abdulaziz Bamusa , Belal Abdulahad Alturkistani ,

Abstract

Background: While relatively rare in type 2 diabetes mellitus (T2DM), diabetic ketoacidosis (DKA) is a serious complication that occurs due to absolute or relative insulin deficiency. Euglycemic DKA (EDKA) is a variant of DKA where patients present with normal blood sugar levels. Recently, studies have reported increased incidence of EDKA associated with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors, medications used to manage blood glucose.
Case Presentation: A 53-year-old man with newly diagnosed T2DM presented with severe nausea and vomiting 4 days after the initiation of empagliflozin/metformin. Laboratory evaluation revealed metabolic acidosis (pH 7.16, bicarbonate 12 mmol/l), elevated anion gap (21 mmol/l), and increased serum ketones, despite near-normal blood glucose levels (7.8 mmol/l, approximately 140 mg/dl). A diagnosis of EDKA was made. The patient was treated with intravenous fluids, insulin therapy, and electrolyte replacement, with discontinuation of the SGLT2 inhibitor. He showed rapid clinical and biochemical improvement and was discharged on insulin therapy, later transitioning to oral agents.
Conclusion: EDKA should be suspected in patients receiving SGLT2 inhibitors who present with unexplained metabolic acidosis, even in the absence of significant hyperglycemia. Early recognition and prompt management are essential to prevent complications. 

Keywords: Diabetes, drug safety, SGLT2i, DKA.