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SGLT2 inhibitor–associated euglycemic diabetic ketoacidosis with hypokalemia — ABIM Board MCQ

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HardAdultsSGLT2 inhibitor–associated euglycemic diabetic ketoacidosis with hypokalemiaABIM Board

A 58-year-old man with type 2 diabetes mellitus is evaluated 18 hours after an urgent laparoscopic colectomy. His medications before admission included metformin and empagliflozin; his last empagliflozin dose was taken on the morning of surgery. He has remained fasting postoperatively and now reports nausea, diffuse abdominal discomfort, and dyspnea. Temperature is 98.8°F, blood pressure is 104/66 mm Hg, pulse is 112/min, and respirations are 28/min with deep breathing. Mucous membranes are dry. Urine output is preserved. Laboratory studies show glucose 182 mg/dL, sodium 139 mEq/L, potassium 3.2 mEq/L, chloride 108 mEq/L, bicarbonate 10 mEq/L, creatinine 1.0 mg/dL, lactate 1.2 mmol/L, and β-hydroxybutyrate 6.4 mmol/L. Venous pH is 7.21. Empagliflozin is discontinued. Which of the following is the most appropriate next step in management?

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Correct answer: D — Start isotonic crystalloid and intravenous potassium, then add intravenous insulin and dextrose when potassium exceeds 3.5 mEq/L

This patient has SGLT2 inhibitor–associated euglycemic diabetic ketoacidosis: recent empagliflozin exposure plus fasting and surgical stress, high-anion-gap metabolic acidosis, and marked ketonemia despite glucose below 250 mg/dL. Treatment requires volume replacement and insulin to suppress ketogenesis; because glucose is already below 250 mg/dL, dextrose must accompany insulin so that insulin can continue until ketoacidosis resolves. However, his potassium is 3.2 mEq/L. Insulin would shift potassium intracellularly and could precipitate life-threatening hypokalemia, arrhythmia, or respiratory muscle weakness. Isotonic crystalloid and intravenous potassium should therefore be started first, with insulin deferred until potassium exceeds 3.5 mEq/L. Intravenous insulin and dextrose are then initiated together. Option B incorrectly starts insulin before correction of significant hypokalemia. Option E may initially appear appropriate because the glucose is not markedly elevated, but insulin treats ketogenesis and must not be withheld based on the glucose concentration. Option A is incorrect because bicarbonate is not routinely indicated at a pH of 7.21 and could aggravate hypokalemia. Option C is inappropriate because this patient has clinically significant acidosis and ketonemia requiring titratable intravenous insulin; subcutaneous rapid-acting insulin is reserved for selected uncomplicated mild or moderate DKA after potassium safety has been addressed.

Reference: Hyperglycaemic crises in adults with diabetes: a consensus report (August 2024) — https://pmc.ncbi.nlm.nih.gov/articles/PMC11343900/ JARDIANCE (empagliflozin) Prescribing Information (October 2025) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/204629s063lbl.pdf