Published: 2021-07-23

Euglycemic diabetic ketoacidosis - a rare side effect of sodium-glucose co-transporter-2 inhibitor in a patient of type 2 diabetes mellitus with left ventricular dysfunction: a case report

Amolpreet Kaur, Parminder Singh, Gifty Singh, Gaurav Mohan, Gaurav Chopra, Rajdeep Singh


A 42 year old female with type 2 diabetes mellitus (T2DM), presented with angina on exertion and left ventricular (LV) dysfunction (global LV ejection fraction (EF)=26%). Patient was subjected to coronary angiography which revealed triple vessel disease. Patient was started on usual standard of care heart failure (HF) medications, including sodium-glucose co-transporter-2 (SGLT-2) inhibitor dapagliflozin which is promising new class of drug for treating T2DM and HF. Patient was advised myocardial revascularization in form of percutaneous transluminal coronary angioplasty (PTCA). Post angioplasty patient developed metabolic acidosis (high anion gap with normal lactate and increased ketone levels). Patient was diagnosed as case of euglycemic diabetic ketoacidosis (DKA) and patient was treated by volume resuscitation and insulin infusion. 


Type 2 diabetes mellitus, Diabetic ketoacidosis, SGLT-2

Full Text:



Lehrke M, Marx N. Diabetes mellitus and heart failure. Am J Cardiol. 2017;120(1):37-47.

Joshi SS, Singh T, Newby DE, Singh J. Sodium-glucose co-transporter 2 inhibitor therapy: mechanisms of action in heart failure. Heart. 2021;107(13).

Barski L, Eshkoli T, Brandstaetter E, Jotkowitz A. Euglycemic diabetic ketoacidosis. Eur J Int Med. 2019;63:9-14.

Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy? Expectations and realities of a new standard of care. Eur Heart J. 2020.

Docherty KF, Jhund PS, Bengtsson O, DeMets DL, Inzucchi SE, Køber L, et al. Effect of Dapagliflozin in DAPA-HF according to background glucose-lowering therapy. Diabetes Care. 2020;43(11):2878-81.

Mosley JF, Everton E, Fellner C. Sodium-glucose linked transporter 2 (SGLT2) inhibitors in the management of type-2 diabetes: a drug class overview. Pharmacy and Therapeutics. 2015;40(7):451.

Taylor SI, Blau JE, Rother KI. SGLT2 inhibitors may predispose to ketoacidosis. The Journal of Clinical Endocrinology & Metabolism. 2015;100(8):2849-52.

Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes care. 2015;38(9):1638-42.

Wang KM, Isom RT. SGLT2 Inhibitor–Induced Euglycemic Diabetic Ketoacidosis: A Case Report. Kidney Med. 2020;2(2):218-21.

Diaz-Ramos A, Eilbert W, Marquez D. Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature. Int J Emerg Med. 2019;12(1):1-4.