Use of Sodium-Glucose Co-Transporter-2 Inhibitors in Type 1 Diabetics: Are the Benefits Worth the Risks?

An Unsuspected Case of Euglycemic Diabetic Ketoacidosis With Twists

Euglycemic diabetic ketoacidosis (EDKA) is defined by acidosis, ketones in serum and urine, and a high anion gap (AG) with a normal glucose level. Sodium-glucose cotransporter-2 (SGLT2) inhibitor has become one of the most common causes of EDKA. We present one of the lowest presenting blood glucose levels for the EDKA in the setting of SGLT2 inhibitor use. A 34-year-old female with a two-year history of type 2 diabetes mellitus (T2DM) presented after accidental ingestion of a metal clip and lack of oral intake for 28 hours. She reported a recent intentional weight loss of 60 lbs. She takes metformin 1000 mg twice daily and empagliflozin 25 mg daily. An urgent endoscopy was planned in the intensive care unit given the proximal location of the foreign body. The basic metabolic profile after the procedure demonstrated a glucose level of 75 mg/dL, bicarbonate level of 11 mmol/L, and AG of 17 mmol/L. The venous pH was 7.27 with a partial pressure of carbon dioxide of 30 mmHg. The urinalysis showed a glucose level greater than 500 μmol/L with a ketone level of 80 μmol/L. The blood and urine toxicology screening results were unremarkable. The patient was treated for EDKA with the administration of intravenous (IV) dextrose 5% in water with subsequent initiation of IV insulin. The assessment of her insulin reserve revealed a low C-peptide of 0.36 ng/mL, a high glutamic acid decarboxylase level greater than 250 IU/mL, and high zinc transporter 8 (ZnT8) antibodies of 42 U/mL, consistent with an undiagnosed transition to latent autoimmune diabetes in adults (LADA). The blood glucose levels for previously reported cases remain between 90 and 250 mg/dL. In this case, the combination of a low carbohydrate diet and prolonged starvation may have led to the impressively low glucose. Additionally, the SGLT2 inhibitor use in patients with LADA serves as one of the known risk factors for EDKA. EDKA poses a diagnostic challenge, especially in the ICU setting where there exists a myriad of causes for high AG metabolic acidosis. Additionally, many of the ICU patients are in a ketotic state brought on by prolonged starvation. Therefore, prompt diagnosis and treatment for EDKA require careful history taking and complete investigation for other causes of high AG metabolic acidosis.