Abstract: SA-PO0264
Delayed Onset Euglycemic Diabetic Ketoacidosis Following SGLT2 Inhibitor Discontinuation
Session Information
- Pharmacology
November 08, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
- 2000 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
Authors
- Drury, Zachary, University of Utah Health, Salt Lake City, Utah, United States
- Abraham, Josephine, University of Utah Health, Salt Lake City, Utah, United States
Introduction
Euglycemic diabetic ketoacidosis (euDKA) is a serious complication of sodium-glucose cotransporter-2 inhibitors. While most cases present shortly after exposure, delayed-onset euDKA after drug discontinuation is rare. Due to its late presentation of acidosis without marked hyperglycemia the diagnosis may be missed or delayed. We report a case of euDKA occurring four days after cessation of dapagliflozin.
Case Description
A 49-year-old man with quadriplegia, autonomic dysreflexia, hypertension, and type 2 diabetes presented to the hospital with hypotension and possible small bowel pneumatosis. He underwent exploratory laparotomy on hospital day (HOD) 0 which was unrevealing. His course was complicated by undifferentiated shock requiring vasoactive support, and acute hypoxic respiratory failure requiring intubation and mechanical ventilation.
By HOD 4, he developed persistent high anion gap metabolic acidosis, hypokalemia, hypophosphatemia, and polyuria. Labs revealed blood glucose of 151 mg/dL, bicarbonate 14 mEq/L, anion gap 19 with normal lactate and an elevated beta-hydroxybutyrate (β-HB) 5.44 mmoL/L with urine glucose >1000. With the worsening acidosis, positive ketones and euglycemia the patient was diagnosed with euDKA and promptly started on an insulin drip with concurrent dextrose. The anion gap normalized and metabolic acidosis resolved within 24 hours of starting the insulin drip and the patient was then transitioned to subcutaneous insulin.
Discussion
This case highlights delayed-onset euDKA, presenting four days after dapagliflozin discontinuation. Although the drug's half-life is 13 hours, its pharmacodynamic effects including persistent glycosuria, suppressed insulin, and increased glucagon can persist well beyond drug clearance.
Clinicians should recognize that the risk of euDKA does not end with the last dose of an SGLT2 inhibitor. Even in the absence of active therapy or hyperglycemia, patients recently exposed to these agents remain at risk, particularly during periods of physiologic stress. Prompt recognition of euDKA and early initiation of insulin with glucose are critical to prevent morbidity. This case underscores the need for heightened clinical suspicion in patients with recent SGLT2i use who develop unexplained anion gap acidosis.