Types of insulinopenia, same outcome

Euglycemic ketoacidosis associated with SGLT2 inhibitors

Abstract

Introduction: Euglycemic ketoacidosis (EKA) is a rare but potentially serious metabolic complication characterized by metabolic acidosis with a high anion gap and ketonemia, without significant hyperglycemia. Its association with sodium-glucose cotransporter 2 (SGLT2) inhibitors has been widely recognized, especially in insulin-deficient contexts.

Objective: to present two cases of euglycemic ketoacidosis associated with the use of SGLT2 inhibitors.

Case presentations: we describe two clinical cases of EKA associated with the use of SGLT2 inhibitors. The first was a 42-year-old woman with latent autoimmune diabetes in adults (LADA) being treated with insulin and empagliflozin, who developed severe metabolic acidosis after an episode of fasting and severe dehydration. The second case was a 51-year-old man with long-term type 2 diabetes and an exhausted pancreatic reserve being treated with a combination of insulin and SGLT2 inhibitors, who developed EKA in the context of a persistent emetic syndrome. In both cases, insulinopenia was confirmed through low or undetectable C-peptide levels.

Discussion and conclusion: SGLT2 inhibitors may induce EKA in patients with insulin deficiency, even in those being treated with exogenous insulin. Prescription of these medications should be personalized, considering the patients’ beta cell functional reserve and educating them on preventive measures. In an expanding therapeutic setting, the approach must be based on the individual’s pathophysiology to optimize the benefits and prevent potentially fatal outcomes