A Case Report: Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain in a Patient on a Low Carbohydrate Diet

Abstract

Introduction: Sodium-glucose cotransporter-2 [SGLT2] inhibitors reduce cardiovascular events and mortality in patients with diabetes, particularly patients with established cardiovascular disease. Euglycemic diabetic ketoacidosis [euDKA], a complication of SGLT2 therapy, can be exacerbated by a low carbohydrate diet. Case Report: A 61-year-old man with a history of type 2 diabetes, taking a SGLT2 inhibitor empagliflozin 10 mg orally daily, presented to the emergency room with a 2-day history of nausea and chest pain. A week prior to presentation, he had started a ketogenic diet. He was initially admitted with a diagnosis of acute coronary syndrome. On initial assessment in the emergency room, his cardiac enzymes were normal and there were no ischemic changes in his ECG. As there was concern for unstable angina, he underwent cardiac catheterization, which showed a known total occlusion with collaterals and arteries with non-obstructive disease without evidence of acute plaque rupture. His baseline laboratory assessments revealed an elevated anion gap of 17, increased urinary and plasma ketones, and metabolic acidosis. His plasma glucose level was 84 mg/dL. The diagnosis of euDKA was made, and treatment with intravenous fluids and insulin was initiated. His chest pain and nausea subsequently resolved. Conclusion: We present a case of euDKA triggered by a ketogenic diet while on SGLT2 inhibitor therapy presenting as chest pain. The recognition of euDKA is important in the context of increased SGLT2 use for management of cardiovascular risk for patients with diabetes.

Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty

“…Vitamin B 12 deficiency, which may lead to cognitive impairment, should also be noted in patients using metformin [200]. A low carbohydrate diet (40%) can increase the production of ketone bodies and euglycemic ketoacidosis in patients using sodium-glucose cotransporter 2 inhibitors [201,202].…”

Scientific evidence underlying contraindications to the ketogenic diet: An update

“…Since the introduction of the glucose lowering class of drugs sodiumglucose cotransporter-2 inhibitors (SGLT2-i), several reports have been published regarding the risk of euglycaemic diabetic ketoacidosis (DKA) in those consuming HFKDs while on SGLT-2 treatment for type 2 diabetes [15][16][17][18][19]. SGLT2-i increase glucose urinary excretion by inhibiting the sodium and glucose reuptake in the kidney.…”

Euglycemic Diabetic Ketoacidosis after Discontinuing SGLT2 Inhibitor

“…No case report was found of a patient who developed EDKA following the start of keto diet for three days duration and stopped all of their oral medication for 2 days. Multiple case reports discussed the development of EDKA in patients who are on a SGLT2 inhibitor after introducing a ketogenic diet for at least one week [ 13 – 16 ]. In our case, the patient's normal level of lactic acid rules out lactic acidosis as a side effect of metformin use as a cause of DKA.…”

“…Laboratory values upon presentation to the emergency department were as follows: glucose 135 mg/dl (70-110 mg/dl)/ 7.5 mmol/l (3.9-6.1 mmol/L), HbA1c 9.7% (4.4-5.6%), sodium 132 mmol/L (136-145 mmol/L), chloride 97 mmol/L (98-107 mmol/L), venous bicarbonate 6 mmol/L (22-26 mmol/L), anion gap 29 [6][7][8][11][12][13][14][15][16], urinary ketones 15 (3+) mmol/l, and urinary glucose 56 (4+) mmol/L. All lab values were taken from venous samples (Table 1).…”

“…Empagliflozin, dapagliflozin, and canagliflozin have all been associated to cause euglycemic diabetic ketoacidosis as well [1,11,12]. Most cases that describe EDKA in patients who are taking SGLT2 inhibitors discuss it in patients who have been on SGLT2 for a period of time who then started a ketogenic diet for one week or more before developing EDKA during their treatment course [13][14][15][16]. A ketogenic diet is defined as a diet where there is significant decrease in the amount of carbohydrates consumed typically to less than 50 g per day with an increase in proportion of fat and protein consumed to very high percentages [17].…”