Euglycemic Diabetic Ketoacidosis in a Patient with Type II Diabetes Mellitus, Ascites and Poor Nutrition on SGLT2 Inhibitor

Title: This is the case of a patient with Euglycemic Diabetic Ketoacidosis (euDKA), ascites, poor nutrition and diabetes mellitus type II on SGLT2 inhibitor. Background: euDKA is an under-reported and under-diagnosed condition that mainly occurs in type I diabetes mellitus patients and in patients with prolonged starvation. The aim of this report is to shed the light on an additional risk factor for euDKA in patients with type I or type II diabetes: SGLT2 inhibitors. Methods and findings: We present the case of a 59 year-old man with type II diabetes on quadruple therapy including canagliflozin who presented for workup of ascites and anorexia and was found to have ketonemia and high anion gap acidosis with acceptable blood glucose levels. Patient’s acidosis and ketonemia did not improve except with the institution of intravenous insulin drip making the diagnosis of euDKA extremely plausible. Conclusion: In diabetic patients on SGLT2 inhibitors with poor oral intake, acidosis should raise a red flag for euDKA.