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Euglycemic DKA — RCPSC IM MCQ

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ModerateEndocrinologyEuglycemic DKARCPSC IM

A 57-year-old woman with type 2 diabetes treated with metformin, ramipril, empagliflozin and basal insulin develops nausea after a low-carbohydrate diet and a viral illness. Her glucose is 11.2 mmol/L, pH 7.18, bicarbonate 10 mmol/L, anion gap 25, beta-hydroxybutyrate is high, and lactate is normal. Urinalysis shows ketones and glycosuria. What is the most likely diagnosis?

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Correct answer: A — Euglycemic diabetic ketoacidosis

SGLT2 inhibitors can precipitate diabetic ketoacidosis with lower glucose concentrations, especially with fasting, low carbohydrate intake, illness or insulin reduction. High anion-gap metabolic acidosis with marked ketonemia confirms DKA despite modest glucose elevation.

Reference: Diabetes Canada 2024 pharmacologic glycemic management update