Euglycemic diabetic ketoacidosis due to a strict low‐carbohydrate diet during treatment with sodium‐glucose cotransporter 2 inhibitors

Abstract

Background: Euglycemic diabetic ketoacidosis is a critical clinical presentation that can occur during treatment with sodium-glucose cotransporter 2 inhibitors. However, little is known regarding how a low-carbohydrate diet in combination with this treatment can increase the risk for this condition. Here, we report a case of euglycemic diabetic ketoacidosis in a patient treated with sodiumglucose cotransporter 2 inhibitors after initiation of a low-carbohydrate diet. Case Presentation: A 54-year-old woman who was taking canagliflozin was transferred to our hospital with severe dyspnea. She had been started on a strict low-carbohydrate diet for 6 days before admission. Laboratory evaluation revealed severe ketoacidosis and a blood glucose level of 196 mg/dL. After her symptoms improved, she was diagnosed with type 1 diabetes mellitus. Conclusion: Although low-carbohydrate diets are recommended for patients with diabetes mellitus, physicians should exercise great caution in recommending low-carbohydrate diets to patients undergoing treatment with sodium-glucose cotransporter 2 inhibitors.

Sodium-Glucose Co-transporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Bariatric Surgery: A Case and Literature Review

“…exposed identifiable precipitants in a series of SGLT2i-associated DKA cases, which indicated risk mitigation potential [ 31 ]. In the literature review, there are few similar DKA cases available regarding patients taking SGLT2i against the backdrop of a low carbohydrate diet [ 32 - 35 ]. Shaikh et al.…”

“…Meyer et al exposed identifiable precipitants in a series of SGLT2i-associated DKA cases, which indicated risk mitigation potential [31]. In the literature review, there are few similar DKA cases available regarding patients taking SGLT2i against the backdrop of a low carbohydrate diet [32][33][34][35]. Shaikh et al and Tauseef et al both share EDKA examples of diabetics on SGLT2i and ketogenic diets between one to three weeks [32,34].…”

Sodium-Glucose Linked Transporter Inhibitors as a Cause of Euglycemic Diabetic Ketoacidosis on a Background of Starvation

“…A few studies report euglycemic DKA due to a low-carbohydrate diet, including one conducted in Japan in which the patient was on canagliflozin and after severely restricting her carbohydrate intake for six days, presented with progressive dyspnea and altered mental status; laboratory investigations revealed severe ketoacidosis and euglycemia [10]. Another case in Taiwan involved a type II diabetic patient on dapagliflozin with a history of poor oral intake for one week attributed to severe toothache who came with the complaints of weakness, dyspnea, nausea, vomiting, and mild abdominal pain; severe metabolic acidosis with an elevated anion gap was discovered upon further investigation [11].…”

Tubular Injury Causing Protracted Glycosuria Following Withdrawal of a Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor: A Possible Role in the Development of Protracted Hypoglycemia and Ketoacidosis

“…The following four points are important in the treatment of SGLT2 inhibitor-associated DKA: (1) Stopping the SGLT2 inhibitor, (2) increasing the insulin dose, (3) providing adequate carbohydrate replacement, and (4) providing adequate fluids (Garg et al 2018;Danne et al 2019). Some case reports of SGLT2 inhibitor-associated DKA have described rapid improvement in symptoms (Fukuyama et al 2020), while others have described persistent acidosis, prolonged positive urine glucose, and osmotic diuresis (Adachi et al 2017;Kelmenson et al 2017;Miyauchi et al 2017;Pujara and Ioachimescu 2017;Wang and Isom 2020).…”