Euglycemic Diabetic Ketoacidosis Accompanied by Severe Hypophosphatemia During Recovery in a Patient With Type 2 Diabetes Being Treated With Canagliflozin/Metformin Combination Therapy

Euglycemic diabetic ketoacidosis (DKA) is defined as acidosis with a blood glucose level <300 mg/dL and bicarbonate level <10 mEq/L and is associated with ketonemia/ketonuria (1). It is usually caused by starvation in conjunction with intercurrent illness in patients with diabetes. This is a relatively uncommon presentation that can go unrecognized. Canagliflozin belongs to the class of sodium–glucose cotransporter 2 (SGLT2) inhibitors and is used for the management of type 2 diabetes. These agents lower blood glucose levels by selectively inhibiting SGLT2 cotransporters expressed in the proximal convoluted tubule of the kidney. Adverse effects include urinary tract infections, genital fungal infections (2), electrolyte abnormality, and DKA (3). During the recovery phase of DKA, hypophosphatemia can develop as a life-threatening condition. However, it is uncommon to have a phosphate level as low as <1 mg/dL (normal range 2.5–5 mg/dL). Herein, we describe the case of a patient with type 2 diabetes who presented with euglycemic DKA within 2 months of starting canagliflozin/metformin therapy. She had severe hypophosphatemia with phosphate levels <1 mg/dL during the recovery phase, requiring repletion of phosphate. A 32-year-old woman with a history of type 2 diabetes presented to the emergency room with a 1-week history of nausea and intractable emesis. Two months earlier, she had started on combination therapy with canagliflozin and metformin. On admission, her laboratory test results were as follows: blood glucose level of 277 mg/dL, anion gap of 19 mmol/L, bicarbonate of 8 mmol/L, serum pH of 7.22, creatinine of 0.81 mg/dL, potassium of 4.4 mEq/L, corrected serum sodium of 129 mmol/L, and positive serum and urine ketones. A diagnosis of euglycemic DKA was made. …