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Euglycaemic DKA due to SGLT2 inhibitor — SCE Acute Medicine MCQ

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HardAcute Renal and Metabolic EmergenciesEuglycaemic DKA due to SGLT2 inhibitorSCE Acute Medicine

A 54-year-old woman with type 2 diabetes on empagliflozin presents with vomiting after bariatric surgery. Glucose is 10.8 mmol/L, ketones are 5.1 mmol/L and venous pH is 7.18. Lactate is 1.4 mmol/L and creatinine is mildly raised. What is the most likely diagnosis?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Euglycaemic diabetic ketoacidosis

SGLT2 inhibitors can precipitate DKA with relatively modest glucose levels, especially after fasting or surgery. The high ketones and acidosis distinguish it from simple starvation ketosis. Lactate is not high enough to explain the acidosis. The pearl is that a normal-ish glucose does not exclude DKA in patients taking SGLT2 inhibitors.

Reference: MHRA SGLT2 inhibitor safety advice; JBDS DKA guideline