Sodium-Glucose Cotransporter-2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis Followed by Excessively Low Carbohydrate Diet

Euglycemic diabetic ketoacidosis (euDKA) is a rare but serious adverse effect caused by sodium-glucose cotransporter-2 (SGLT2) inhibitors, and it can be challenging to identify in the emergency room (ER). In this report, we present a case of a type 2 diabetic patient whose diagnosis was delayed due to the absence of marked hyperglycemia. A 39-year-old female presented to the ER with a four-day history of nausea, vomiting, sweating, dyspnea, and generalized weakness after initiating dapagliflozin, along with a low carbohydrate diet and moderate exercise to curb her newly diagnosed type 2 diabetes mellitus (DM). However, this had resulted in strict avoidance of carbohydrates. Despite seeking medical attention twice, a proper diagnosis had been delayed due to the absence of marked hyperglycemia. Her blood glucose level at our hospital was 181 mg/dl and urine analysis showed ketonuria and glucosuria. She was admitted to the ICU with a diagnosis of euDKA related to SGLT2 inhibitor use. She was successfully treated with insulin and glucose supplementation.