Understanding Euglycemic Diabetic Ketoacidosis: A Serious but Rare Side Effect of SGLT2 Inhibitors

Diabetic ketoacidosis (DKA) is a serious medical emergency where the blood becomes dangerously acidic due to a buildup of ketones—byproducts of the body breaking down fat too quickly. Normally, DKA is associated with very high blood sugar levels. However, a rarer form called euglycemic diabetic ketoacidosis (EuDKA) can occur even when blood glucose remains below 250 mg/dL (13.9 mmol/L).

EuDKA can happen in people with type 2 diabetes who take sodium-glucose co-transporter-2 inhibitors (SGLT2i)—a class of diabetes medications that work by allowing the kidneys to remove excess glucose through urine. While these medications are generally safe and effective, EuDKA is a recognized but uncommon complication.

Researchers at an intensive care unit in North Queensland analyzed 14 cases of SGLT2i-associated EuDKA between 2017 and 2023 and compared them to 31 cases of traditional type 1 diabetes DKA. The study revealed important differences in how these two forms of ketoacidosis present and behave.

Patients with EuDKA were typically older and had more accompanying health conditions than those with type 1 diabetes DKA. Interestingly, First Nations Australians were overrepresented in the EuDKA group, suggesting possible differences in disease prevalence or access to care.

While EuDKA caused milder initial biochemical changes than type 1 diabetes DKA, it required significantly longer treatment. Patients needed extended insulin therapy and stayed in intensive care longer, even though the time needed to resolve the acidosis was similar between the two groups.

The study found that EuDKA typically develops when a triggering event occurs in someone taking SGLT2 inhibitors. Common triggers included fasting, caloric restriction (such as dieting or skipping meals), and intercurrent illnesses like infections or viral conditions.

The presenting symptoms were variable and could overlap, making EuDKA potentially harder to recognize than traditional DKA. Because blood glucose levels aren't dramatically elevated, healthcare providers might not immediately suspect ketoacidosis, which could delay diagnosis and treatment.

The study identified certain factors associated with worse outcomes and longer hospital stays. Patients with type 2 diabetes who had complications affecting other organs (kidney, heart, or eye damage) tended to stay in intensive care longer when they developed EuDKA.

Additionally, patients who were obese or who had been taking insulin before admission experienced longer periods of acidosis, suggesting that these factors may complicate recovery.

If you are taking an SGLT2 inhibitor, this research does not suggest you should stop your medication—EuDKA remains uncommon. However, it is important to be aware of the condition and its triggers.

Avoid prolonged fasting or severe caloric restriction without discussing it with your healthcare provider first. If you become ill or are facing surgery or a procedure that might affect your eating, contact your doctor about how to manage your SGLT2 inhibitor safely. Seek urgent medical care if you experience nausea, vomiting, unusual shortness of breath, or persistent fatigue, even if your blood sugar is not particularly high.

This study adds to our understanding of a rare but serious complication, helping healthcare providers better recognize and treat EuDKA in intensive care settings.

Source: Anaesthesia and intensive care. Evidence type: PubMed indexed literature. Type1Cure is an information and intelligence hub, not a medical advice service. This article summarizes published research and does not provide diagnosis, treatment, or personal medical guidance. Always talk to your own care team before changing anything about your Type 1 diabetes management.