Euglycemic Diabetic Ketoacidosis in a Patient Prescribed Empagliflozin and a Ketogenic Diet: A Case of Misdiagnosed Type 1 Diabetes

Diabetic ketoacidosis (DKA) is defined as a biochemical triad of hyperglycemia (blood glucose >250 mg/dL), ketonemia/ketonuria, and high anion-gap metabolic acidosis (AGMA). Although hyperglycemia is a distinct characteristic in DKA (1), a euglycemic DKA (EDKA) variant exists in which a patient’s blood glucose is normal or mildly elevated on presentation. Sodium–glucose cotransporter 2 (SGLT2) inhibitors such as empagliflozin and dapagliflozin, approved by the U.S. Food and Drug Administration (FDA) for the treatment of type 2 diabetes, have been reported to increase the risk of EDKA, especially in patients with type 1 diabetes (2). We present a unique case of EDKA associated with SGLT2 inhibitor use that was complicated by ketosis induced by a ketogenic diet and unmasking underlying type 1 diabetes in a patient previously treated as having type 2 diabetes. A 70-year-old Caucasian woman with a medical history significant for type 2 diabetes and hypothyroidism presented to the emergency department (ED) with shortness of breath and dizziness for 4 days, associated with one episode of nausea and vomiting. On presentation, she had normal vital signs except for tachycardia. The remainder of her physical exam was unremarkable. Her BMI was 21.8 kg/m2. Her initial diagnostic work-up is summarized in Table 1. View this table: TABLE 1 Laboratory Values on Presentation and Associated Reference Ranges Six months before her presentation, the patient relocated and began receiving primary care in our health system. Before that time, her diabetes was comanaged by a different primary care provider and an endocrinologist. Oral agents had not adequately controlled her blood glucose, and she had been transitioned to insulin. On initial evaluation in our health system, her diabetes was inadequately controlled (as reflected by an A1C of 8.7%) with long-acting subcutaneous insulin glargine 10 units daily …