From the Research
Euglycemic diabetic ketoacidosis (DKA) is diagnosed when a patient has ketoacidosis with normal or near-normal blood glucose levels (typically less than 250 mg/dL), and the diagnostic criteria include a blood glucose level less than 250 mg/dL, presence of metabolic acidosis with a pH less than 7.3 or bicarbonate less than 18 mEq/L, and positive serum or urine ketones, as stated in the most recent study 1. The diagnostic criteria for euglycemic DKA include:
- Blood glucose level less than 250 mg/dL
- Presence of metabolic acidosis with a pH less than 7.3 or bicarbonate less than 18 mEq/L
- Positive serum or urine ketones
- Anion gap greater than 10-12 mEq/L, typically present in these patients This condition often occurs in patients with type 1 diabetes who are taking SGLT2 inhibitors (such as empagliflozin, dapagliflozin, or canagliflozin), during pregnancy, after alcohol consumption, or in states of starvation or reduced carbohydrate intake, as mentioned in 2, 3, 4, 5.
Pathophysiology and Treatment
The pathophysiology involves insulin deficiency leading to ketone body production despite normal glucose levels, often because SGLT2 inhibitors cause glucose excretion in urine while not preventing ketogenesis, as explained in 1. Treatment follows standard DKA protocols with IV fluids, insulin therapy, and electrolyte replacement, but may require administration of dextrose alongside insulin to prevent hypoglycemia, as recommended in 4, 5.
Clinical Considerations
Clinicians should maintain a high index of suspicion for euglycemic DKA in at-risk patients presenting with symptoms of DKA but normal glucose levels, as delayed diagnosis can lead to serious complications, as emphasized in 2, 3, 4, 5, 1. It is essential to monitor anion gap and ketones to guide insulin and fluid management, and a slower transition to subcutaneous insulin may be necessary to prevent a relapse, as proposed in 1.