A 47-year-old woman with type 2 diabetes on an SGLT2 inhibitor presents with two days of nausea, vomiting, and reduced oral intake. Glucose is 168 mg/dL, pH 7.21, bicarbonate 12 mEq/L, and urine ketones are strongly positive. The most likely explanation for her presentation is:
- A Lactic acidosis from metformin accumulation
- B Starvation ketosis alone
- C Euglycaemic diabetic ketoacidosis due to impaired glucosuria and increased lipolysis ✓
- D Alcoholic ketoacidosis
Correct answer: C. Euglycaemic diabetic ketoacidosis due to impaired glucosuria and increased lipolysis
Explanation
SGLT2 inhibitors cause glucosuria independent of glycaemia, so during illness with poor intake, blood glucose may remain below 250 mg/dL while ketogenesis proceeds. The combination of acidosis, ketosis, and near-normal glucose on an SGLT2 inhibitor defines euglycaemic DKA. Starvation and alcoholic ketoacidosis are usually less acidotic and lack the drug context; metformin-associated lactic acidosis shows a high lactate, not ketones.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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