Journal of Medicine and Life Science

Institute for Medical Science (제주대학교 의과학연구소)
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Euglycemic diabetic ketoacidosis development in a patient with type 2 diabetes receiving a sodium-glucose cotransporter-2 inhibitor and a carbohydrate-restricted diet

  • Gwanpyo Koh (Department of Internal Medicine, Jeju National University College of Medicine) ;
  • Jisun Bang (Department of Internal Medicine, Jeju National University Hospital) ;
  • Soyeon Yoo (Department of Internal Medicine, Jeju National University College of Medicine) ;
  • Sang Ah Lee (Department of Internal Medicine, Jeju National University College of Medicine)
  • Received : 2023.06.07
  • Accepted : 2023.08.31
  • Published : 2023.09.30
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Abstract

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have become increasingly prescribed because of their proven protective effects on the heart and kidneys, and carbohydrate-restricted diets are popular therapeutic approaches for patients with obesity and diabetes. A 28-year-old obese woman with recently diagnosed diabetes developed euglycemic diabetic ketoacidosis (DKA) while on dapagliflozin, an SGLT2 inhibitor, and following a carbohydrate-restricted diet. She presented with nausea, vomiting, and epigastric pain. Hospital tests showed a blood glucose of 172 mg/dL, metabolic acidosis, and increased ketone levels, confirming euglycemic DKA. Treatment involved discontinuing dapagliflozin and administering fluids, glucose, and insulin. She recovered and was discharged on the fourth day. This is considered a case of euglycemic DKA induced by SGLT2 inhibitors and triggered by a carbohydrate-restricted diet. This case highlights the importance of physicians in confirming the symptoms and laboratory results of DKA, even in patients with normal blood glucose levels taking SGLT2 inhibitors and following carbohydrate-restricted diets. It is also crucial to advise patients to maintain an adequate carbohydrate intake.

Keywords

Acknowledgement

This work was supported by the 2023 education, research and student guidance grant funded by Jeju National University.

References

  1. ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, et al. 9. Pharmacologic approaches to glycemic treatment: standards of care in diabetes-2023. Diabetes Care 2023;46(Suppl 1):S140-57. https://doi.org/10.2337/dc23-S009
  2. Hsia DS, Grove O, Cefalu WT. An update on sodium-glucose co-transporter-2 inhibitors for the treatment of diabetes mellitus. Curr Opin Endocrinol Diabetes Obes 2017;24:73-9. https://doi.org/10.1097/MED.0000000000000311
  3. Inoue A, Katayama A, Sue M, Hasegawa M, Maeda M, Matoba M, et al. Euglycemic diabetic ketoacidosis in a patient with type 2 diabetes mellitus 3days after initiating sodium-glucose cotransporter 2 inhibitor while on an extremely low carbohydrate diet: a case report. Clin Case Rep 2022;10:e6572.
  4. Mistry S, Eschler DC. Euglycemic diabetic ketoacidosis caused by SGLT2 inhibitors and a ketogenic diet: a case series and review of literature. AACE Clin Case Rep 2020;7:17-9. https://doi.org/10.1016/j.aace.2020.11.009
  5. Choi JH, Cho YJ, Kim HJ, Ko SH, Chon S, Kang JH, et al. Effect of carbohydrate-restricted diets and intermittent fasting on obesity, type 2 diabetes mellitus, and hypertension management: consensus statement of the Korean Society for the Study of Obesity, Korean Diabetes Association, and Korean Society of Hypertension. Diabetes Metab J 2022;46:355-76. https://doi.org/10.4093/dmj.2022.0038
  6. Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42:731-54. https://doi.org/10.2337/dci19-0014
  7. Palmer BF, Clegg DJ. Euglycemic ketoacidosis as a complication of SGLT2 inhibitor therapy. Clin J Am Soc Nephrol 2021;16:1284-91. https://doi.org/10.2215/CJN.17621120
  8. Health Insurance Review & Assessment Service. Standards for approving Korean National Health Insurance coverage of medications used for the treatment of diabetes [Internet]. Wonju: Korean Health Insurance Review & Assessment Service; c2023 [cited 2023 Apr 25]. Available from: https://www.hira.or.kr/rc/insu/insuadtcrtr/InsuAdtCrtrList.do?pgmid=HIRAA030069000400&WT.ac=%EB%B3%B4%ED%97%98%EC%9D%B8%EC%A0%95%EA%B8%B0%EC%A4%80%EB%B0%94%EB%A1%9C%EA%B0%80%EA%B8%B0.
  9. Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 2013;67:789-96. https://doi.org/10.1038/ejcn.2013.116
  10. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239-52. https://doi.org/10.1016/j.diabres.2018.02.026