Vol 10, No 2 (2021)
Case report
Published online: 2021-02-12

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Euglycemic diabetic ketoacidosis associated with empagliflozin in patients hospitalized with acute pulmonary embolism

Kevin Wibawa1, Ferica Valentine Kuhuwael2, Caesar Rio Julyanto Putra1, Sandra Utami Widiastuti2, Leonardo Paskah Suciadi3
Clin Diabetol 2021;10(2):204-208.


Euglycemic diabetic ketoacidosis (Eu-DKA) is a rare but life-threatening complication in diabetic patient treated with sodium-glucose cotransporter 2 inhibitors (SGLT2i). A 71-year-old diabetic female treated with empagliflozin presented to the ED with shortness of breath. Diagnosis of acute pulmonary embolism was confirmed initially. She was treated conservatively with subcutaneous enoxaparin 60 mg bidaily. and oxygen therapy.  Respiratory distress associated with anion gap — metabolic acidosis and ketosis developed on the following days however her blood glucose levels were always within normal limit. Clinical recovery was gained after stopping the drug, administering rehydration, and insulin drip. Complica-tion of DKA without hyperglycaemia should be consid-ered while evaluating ketoacidosis in diabetic patients treated with SGLT2i, particularly in critical illness cases.

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  1. Ogawa W, Sakaguchi K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. J Diabetes Investig. 2016; 7(2): 135–138.
  2. Wang KM, Isom RT. SGLT2 inhibitor-induced euglycemic diabetic ketoacidosis: a case report. Kidney Med. 2020; 2(2): 218–221.
  3. Rosenstock J, Ferrannini E, Rosenstock J, et al. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care. 2015; 38(9): 1638–1642.
  4. Barski L, Eshkoli T, Brandstaetter E, et al. Euglycemic diabetic ketoacidosis. Eur J Intern Med. 2019; 63: 9–14.
  5. Benmoussa J, Clarke M, Penmetsa A, et al. Euglycemic diabetic ketoacidosis: The clinical concern of SGLT2 inhibitors. Journal of Clinical and Translational Endocrinology: Case Reports. 2016; 2: 17–19.
  6. Candelario N, Wykretowicz J. The DKA that wasn't: a case of euglycemic diabetic ketoacidosis due to empagliflozin. Oxf Med Case Reports. 2016; 2016(7): 144–146.
  7. Sampani E, Sarafidis P, Papagianni A. Euglycaemic diabetic ketoacidosis as a complication of SGLT-2 inhibitors: epidemiology, pathophysiology, and treatment. Expert Opin Drug Saf. 2020; 19(6): 673–682.
  8. Yu X, Zhang S, Zhang L. Newer perspectives of mechanisms for euglycemic diabetic ketoacidosis. Int J Endocrinol. 2018; 2018: 7074868.
  9. Diaz-Ramos A, Eilbert W, Marquez D. Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature. Int J Emerg Med. 2019; 12(1): 27.
  10. Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015; 38(9): 1687–1693.
  11. Goldenberg RM, Berard LD, Cheng AYY, et al. SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis. Clin Ther. 2016; 38(12): 2654–2664.e1.
  12. Bonner C, Kerr-Conte J, Gmyr V, et al. Inhibition of the glucose transporter SGLT2 with dapagliflozin in pancreatic alpha cells triggers glucagon secretion. Nat Med. 2015; 21(5): 512–517.
  13. Kuhre RE, Ghiasi SM, Adriaenssens AE, et al. No direct effect of SGLT2 activity on glucagon secretion. Diabetologia. 2019; 62(6): 1011–1023.
  14. Saponaro C, Mühlemann M, Acosta-Montalvo A, et al. Interindividual heterogeneity of SGLT2 expression and function in human pancreatic islets. Diabetes. 2020; 69(5): 902–914.
  15. Bonora BM, Avogaro A, Fadini GP. Euglycemic ketoacidosis. Curr Diab Rep. 2020; 20(7): 25.