A patient on empagliflozin presents to the ER with nausea, vomiting, and Kussmaul breathing. Blood glucose is 160 mg/dL, pH 7.18, and urine ketones are strongly positive. Which statement best describes this complication of SGLT2 inhibitors?
- A This is diabetic ketoacidosis and blood glucose is always >250 mg/dL with SGLT2 inhibitors
- B This is lactic acidosis due to metformin co-administration
- C This is euglycemic DKA, where glucose may be <250 mg/dL, triggered by insulin deficiency or illness ✓
- D This is hyperosmolar hyperglycemic state, not DKA
Correct answer: C. This is euglycemic DKA, where glucose may be <250 mg/dL, triggered by insulin deficiency or illness
Explanation
SGLT2 inhibitors can cause euglycemic DKA, where blood glucose may be <250 mg/dL due to increased urinary glucose excretion. The mechanism involves reduced insulin, increased glucagon, and enhanced lipolysis. Patients may have relatively normal glucose levels, delaying diagnosis. It can occur in type 1 and type 2 DM. Metformin causes lactic acidosis, not DKA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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