UMEM Educational Pearls

Euglycemic DKA (eDKA) is a medical emergency requiring prompt attention. It is caused by an imbalance of insulin and glucagon leading to ketone accumulation (1-3). In addition to typical risk factors for DKA, those for eDKA include SGLT-2 inhibitor use and pregnancy, with 30% of DKA cases in pregnancy presenting euglycemic (4, 5).

eDKA presents with an anion gap metabolic acidosis, ketosis/ketonuria, & blood glucose less than 250 mg/dL.

Diagnosis requires ruling out other causes of anion gap metabolic acidosis, including toxic ingestions.

The cornerstone of eDKA management is ensuring enough dextrose to allow needed insulin administration to reverse ketone accumulation.

Pitfalls

• Not giving enough insulin to reverse ketosis due to concern about low blood sugars
• Not giving enough dextrose to support sufficient insulin dosing
• Not uptitrating insulin for refractory acidosis caused by eDKA

Pearls

• Start insulin with at least 0.05 units/kg/hour along with IV dextrose (3,5,7,9)
• Start IV dextrose at 5-10 g/hr (9). This will be 100-200 mL/hr of a 5% dextrose solution (dextrose should be added to either normal or ½ normal saline to avoid causing hyponatremia!)
  • Dextrose concentrations: D5 = 50 g/L || D10 = 100 g/L || D20 = 200 g/L
• Euglycemic DKA may present WITHOUT ketonuria if the patient is on an SGLT-2 inhibitor (7,8) – send a beta hydroxybutyrate!
• eDKA is most common in the first two months of SGLT-2 inhibitor use, but can happen at any time (6)

References

1. McCabe, D. E., Strollo, B. P. & Fuhrman, G. M. Euglycemic Diabetic Ketoacidosis in the Surgical Patient. Am. Surg. 89, 1083–1086 (2023).

2. Chaudhry, A., Roels, C. & Lee, J. Sodium–Glucose Cotransporter-2 Inhibitor–associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery. Can. J. Diabetes 46, 843–850 (2022).

3. Wan Azman, S. S., Sukor, N., Abu Shamsi, M. Y., Ismail, I. & Kamaruddin, N. A. Case Report: High-Calorie Glucose Infusion and Tight Glycemic Control in Ameliorating Refractory Acidosis of Empagliflozin-Induced Euglycemic Diabetic Ketoacidosis. Front. Endocrinol. 13, 867647 (2022).

4. Jaber, J. F., Standley, M. & Reddy, R. Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature. Case Rep. Crit. Care 2019, 1–5 (2019).

5. Algaly, G., Abdelrahman, A. & Ahmed, S. M. I. Euglycemic diabetic ketoacidosis in a pregnant woman. J. Am. Coll. Emerg. Physicians Open 4, e13089 (2023).

6. Dutta, S. et al. Euglycemic diabetic ketoacidosis associated with SGLT2 inhibitors: A systematic review and quantitative analysis. J. Fam. Med. Prim. Care 11, 927 (2022).

7. Koceva, A. & Kravos Tramšek, N. A. From Sweet to Sour: SGLT-2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis. J. Pers. Med. 14, 665 (2024).

8. Juneja, D., Nasa, P., Jain, R. & Singh, O. Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports. World J. Diabetes 14, 1314–1322 (2023).

9. Albert, S. G., Shrestha, E. & Wood, E. M. Euglycemic diabetic ketoacidosis: The paradox of delayed correction of acidosis. Diabetes Metab. Syndr. Clin. Res. Rev. 17, 102848 (2023).