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Euglycaemic DKA from SGLT2i — EECC MCQ

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ModerateHeart FailureEuglycaemic DKA from SGLT2iEECC

A 65-year-old man with HFrEF (LVEF 25%) and diabetes develops diabetic ketoacidosis (DKA) while on empagliflozin. His blood glucose is only 12 mmol/L (not markedly elevated). What is this phenomenon?

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Correct answer: B — Euglycaemic diabetic ketoacidosis (eDKA) — SGLT2 inhibitors can cause DKA with near-normal or only mildly elevated blood glucose, making diagnosis challenging; empagliflozin should be stopped immediately with standard DKA management

Euglycaemic DKA (eDKA) is a rare but serious adverse effect of SGLT2 inhibitors (incidence ~0.1-0.2%). The mechanism: SGLT2 inhibition causes glycosuria, lowering blood glucose and reducing insulin secretion, while simultaneously increasing glucagon secretion — promoting lipolysis and ketogenesis. Unlike classical DKA (blood glucose >14 mmol/L), eDKA presents with near-normal glucose (<14 mmol/L), making diagnosis challenging. Risk factors: fasting/dehydration, surgery, illness, low-carbohydrate diet, excessive alcohol, type 1 diabetes (SGLT2i not recommended in T1DM). Diagnosis: metabolic acidosis + elevated ketones (blood beta-hydroxybutyrate >3 mmol/L) despite relatively normal glucose. The MHRA and ESC guidelines recommend: stop SGLT2i 2-3 days before surgery, hold during acute illness, and educate patients about sick day rules.

Reference: ESC (2023): HF Guidelines; MHRA SGLT2i Safety Alert