A 49-year-old man with type 2 diabetes on empagliflozin presents with 2 days of vomiting and abdominal pain. Glucose is 214 mg/dL, pH 7.18, bicarbonate 9 mEq/L, anion gap 24, serum and urine ketones strongly positive. He is alert, BP 108/70 mmHg. After starting intravenous fluids, the single most important adjustment to his treatment is:
- A Stop empagliflozin and add dextrose-containing fluids alongside insulin even though glucose is below 250 mg/dL ✓
- B Stop insulin entirely since glucose is near-normal and give only saline
- C Give a bolus of 50% dextrose alone without insulin
- D Continue empagliflozin and add metformin to improve ketone clearance
Correct answer: A. Stop empagliflozin and add dextrose-containing fluids alongside insulin even though glucose is below 250 mg/dL
Explanation
SGLT2 inhibitors cause euglycemic diabetic ketoacidosis: profound ketosis and acidosis with glucose typically below 250 mg/dL because of glucosuria. Management follows standard DKA principles with one key modification, dextrose is added to intravenous fluids early to permit continued insulin infusion until the anion gap closes, despite modest glucose values. Empagliflozin must be stopped. Insulin is essential; withholding it perpetuates lipolysis and ketogenesis. Metformin has no role here and risks lactic acidosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.