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Euglycaemic DKA — RACP Adult Medicine MCQ

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ModerateEmergency MedicineEuglycaemic DKARACP Adult Medicine

A 52-year-old man with type 2 diabetes on metformin and empagliflozin presents with abdominal pain, nausea, and vomiting. His blood glucose is 12 mmol/L (not markedly elevated), pH is 7.18, bicarbonate 10 mmol/L, anion gap 22, and blood ketones 5.5 mmol/L. What is the most likely diagnosis?

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Correct answer: B — Euglycaemic diabetic ketoacidosis

SGLT2 inhibitor-associated euglycaemic DKA presents with ketoacidosis (elevated ketones, metabolic acidosis) but near-normal or only mildly elevated blood glucose. The mechanism involves increased glucosuria (lowering glucose), reduced insulin secretion, and increased glucagon with enhanced lipolysis and ketogenesis. Risk factors include intercurrent illness, surgery, reduced carbohydrate intake, and dehydration. Management is the same as standard DKA. SGLT2 inhibitors should be held perioperatively and during acute illness.

Reference: eTG – 2025 – Endocrinology; TGA – 2024 – SGLT2 Inhibitor Safety Alert