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SGLT2 inhibitor-associated euglycemic diabetic ketoacidosis — ABIM Board MCQ

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HardEndocrinology/MetabolismSGLT2 inhibitor-associated euglycemic diabetic ketoacidosisABIM Board

A 59-year-old man with type 2 diabetes treated with empagliflozin presents with nausea and abdominal pain after 2 days of poor intake. Glucose is 178 mg/dL, bicarbonate is 11 mEq/L, anion gap is 24, beta-hydroxybutyrate is elevated, and lactate is normal. Which of the following is the most likely cause?

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Correct answer: C — SGLT2 inhibitor-associated euglycemic ketoacidosis

SGLT2 inhibitors increase risk of ketoacidosis with relatively modest glucose levels, particularly during fasting, acute illness, surgery, or reduced insulin. Treatment is fluids, insulin with dextrose as needed, electrolyte correction, and stopping the SGLT2 inhibitor.

Reference: ADA Standards of Care in Diabetes 2026; FDA SGLT2 Safety Communication