Euglycemic diabetic ketoacidosis: A missed diagnosis

Abstract

Euglycemic diabetic ketoacidosis (DKA) is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose (less than 11 mmol/L). The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units; it may delay diagnosis and treatment causing worse outcomes. Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus. With the addition of sodium/ glucose cotransporter-2 inhibitors in diabetes mellitus management, euglycemic DKA incidence has increased. The other causes of euglycemic DKA include pregnancy, fasting, bariatric surgery, gastroparesis, insulin pump failure, cocaine intoxication, chronic liver disease and glycogen storage disease. The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit, milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio. Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones. The diagnostic workup includes arterial blood gas for metabolic acidosis, serum ketones and exclusion of other causes of high anion gap metabolic acidosis. Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement. The dextrose-containing fluids should accompany intravenous insulin to correct metabolic acidosis, ketonemia and to avoid hypoglycemia.

Keywords: Diabetic Ketoacidosis; Sodium/glucose co-transporter-2 inhibitors; Pregnancy with diabetic ketoacidosis; Diabetes complications; Pregnancy in diabetes; Ketosis; Metabolic acidosis

Core Tip: Euglycemia diabetic ketoacidosis (DKA) is an uncommon, life-threatening emergency with lower normal blood glucose. Euglycemic DKA can occur in both types of diabetes mellitus, and the absence of hyperglycemia may delay diagnosis with worse outcomes. The use of sodium/glucose cotransporter-2 (SGLT-2) inhibitors as a therapeutic option in the management of diabetes mellitus has increased the incidence of euglycemic DKA. Euglycemic DKA should be considered in any unexplained metabolic acidosis with a history of diabetes mellitus and associated risk factors. Patients on SGLT-2 inhibitors must be educated about potential risk factors for euglycemic DKA and dose adjustment for sick days.