Since the approval of
sodium-glucose cotransporter 2 (
SGLT2) inhibitors by the US Food and Drug Administration for
type 2 diabetes, there have been several reports of euglycemic
diabetic ketoacidosis in patients using this class of medication. We present a case of euglycemic
diabetic ketoacidosis where
ketonemia and glucosuria persisted well beyond the expected effect of
dapagliflozin. Our patient is a 50-year-old woman with
type 2 diabetes since age 35 who was taking
metformin and
dapagliflozin. She presented with
fatigue,
constipation, and 3 days of reduced oral intake. Laboratory data indicated anion gap
acidosis,
ketonemia, severe
hypokalemia, and minimally elevated
blood glucose. She was treated with sliding scale
short-acting insulin and
electrolyte replacement until hospital day 6, when endocrinology was consulted. An
insulin drip was initiated due to persistent
ketonemia and reopening of the anion gap, despite improved oral intake and normoglycemia. On stopping the
insulin drip on day 9, the β-hydroxybutyrate increased again. It finally stabilized within normal range with the initiation of basal subcutaneous
insulin. This case indicates that clinical effects of
dapagliflozin persist much longer than the reported half-life of 12.9 hours would predict. To prevent this potentially dangerous complication, patients taking
SGLT2 inhibitors who become ill should discontinue the medication, undergo
ketone evaluation, and start basal
insulin, if
ketones are positive. In addition, patients should be educated to stop their
SGLT2 inhibitor at least 1 week prior to elective procedures.