A 45-year-old woman with type 2 diabetes on empagliflozin presents with nausea, vomiting and abdominal pain. Glucose is 168 mg/dL, pH 7.21, bicarbonate 12 mEq/L, urine ketones strongly positive. She stopped eating two days ago due to gastroenteritis. The most likely diagnosis is:
- A Euglycemic ketoacidosis induced by the SGLT2 inhibitor ✓
- B Diabetic ketoacidosis with concomitant hyperosmolar state
- C Lactic acidosis from occult sepsis
- D Starvation ketosis alone
Correct answer: A. Euglycemic ketoacidosis induced by the SGLT2 inhibitor
Explanation
SGLT2 inhibitors cause glucosuria that caps blood glucose while promoting lipolysis, ketogenesis and reduced renal ketone clearance, producing ketoacidosis at near-normal glucose levels. Triggers include illness, poor intake, surgery and alcohol. Starvation ketosis alone does not produce acidosis of this severity, and lactic acidosis would show a markedly elevated lactate with a different anion gap composition. Management includes stopping the drug, fluids, dextrose-containing insulin infusion.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.