Abstract: TH-PO0436
Atypical Presentation of Euglycemic Diabetic Ketoacidosis in SGLT2 Inhibitor Use Precipitated by Ketogenic Diet
Session Information
- Fluid, Electrolyte, and Acid-Base Disorders: Clinical - 1
November 06, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Fluid, Electrolytes, and Acid-Base Disorders
- 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical
Authors
- Singaravel, Kavitha, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
- Bathi, Srikar, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
- Teggihal, Anagha, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
- Manahan, Ferdinand J., Geisinger Community Medical Center, Scranton, Pennsylvania, United States
- Cortese, James, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
Introduction
Euglycemic diabetic ketoacidosis (euDKA) has been increasingly associated with SGLT2 inhibitor use and, recently, concomitant carbohydrate-restricted diets. We present a case of euDKA in a patient with type 2 diabetes mellitus on an SGLT 2 inhibitor and recent ketogenic diet presenting with atypical symptoms.
Case Description
A 62-year-old male with a history of type 2 diabetes mellitus, JAK2-negative erythrocytosis, presented with a 1-week history of malaise, nausea, and blurry vision, followed by 3 days of progressive dyspnea after initiating a ketogenic diet 1 week prior.
He had sinus tachycardia and was saturating well on room air. Workup revealed hemoglobin 20 g/dL, sodium 132 mmol/L, bicarbonate 10 mmol/L, glucose 178 mg/dL, anion gap 32, and venous pH 7.15. Urinalysis showed ketonuria. Hemoglobin A1c was 11.1%. CT pulmonary angiogram ruled out pulmonary embolism.
He was initially managed with an intravenous bicarbonate infusion and isotonic fluids. Nephrology was consulted, and he was diagnosed with euDKA, based on the presence of ketonuria, metabolic acidosis, and use of an SGLT2 inhibitor solely for diabetes. He was started on D51/2 NS and insulin per DKA protocol with resolution of symptoms.
Evaluation for latent autoimmune diabetes in adults due to recent weight loss and glycemic deterioration was negative. Cardiac catheterization revealed nonobstructive coronary artery disease. Pulmonology attributed dyspnea to severe metabolic acidosis in the absence of underlying pulmonary pathology. Symptoms resolved on treating euDKA, and he was discharged home.
Discussion
In this case, the combination of carbohydrate restriction and SGLT2 inhibition likely synergistically contributed to the development of euDKA. Use of SGLT2 inhibitors promotes glycosuria and can precipitate ketosis even in the absence of significant hyperglycemia. Low-carbohydrate diets can lead to increased ketone production, and when combined with SGLT2 inhibitors, the risk of euDKA may be heightened. Visual disturbances, a symptom not commonly associated with euDKA, is rare and may be related to osmotic shifts or other metabolic disturbances. Clinicians should maintain a high index of suspicion for euDKA to ensure prompt diagnosis and consider screening patients with T2DM on SGLT2 inhibitors who adopt low-carbohydrate diets