From the Guidelines
Your risk of developing euglycemic diabetic ketoacidosis (DKA) is generally low based solely on a family history of type 2 diabetes. Euglycemic DKA is a rare condition where ketoacidosis occurs without significantly elevated blood glucose levels (typically below 250 mg/dL). While family history of type 2 diabetes increases your risk for developing diabetes itself, euglycemic DKA is most commonly associated with specific triggers rather than genetic predisposition. These triggers include SGLT2 inhibitor medications (like empagliflozin, dapagliflozin, canagliflozin), prolonged fasting, pregnancy, excessive alcohol consumption, or severe illness. If you have diabetes and take SGLT2 inhibitors, your risk increases substantially, and you should be aware of symptoms like nausea, vomiting, abdominal pain, excessive thirst, frequent urination, and fatigue - even if your blood sugar readings aren't very high. Regular monitoring of both blood glucose and ketones (especially during illness) is important if you develop diabetes, as noted in the 2025 standards of care in diabetes 1. The underlying mechanism involves insulin deficiency relative to needs, causing the body to break down fat for energy, producing ketones that acidify the blood, while SGLT2 inhibitors can mask hyperglycemia by increasing glucose excretion in urine. Some key points to consider:
- The incidence of DKA in people with type 2 diabetes treated with SGLT2 inhibitors is estimated to be 0.6–4.9 events per 1,000 patient-years 1.
- Risk factors for DKA in individuals with type 2 diabetes treated with SGLT2 inhibitors include very-low-carbohydrate diets, prolonged fasting, dehydration, excessive alcohol intake, and other common precipitating factors 1.
- Up to a third of people treated with SGLT2 inhibitors who developed DKA present with glucose levels <200 mg/dL (11.1 mmol/L) 1. Given the low risk associated with family history alone and the specific triggers for euglycemic DKA, it's essential to focus on managing and monitoring diabetes if you develop it, rather than the risk of euglycemic DKA itself, as supported by the most recent guidelines 1.
From the Research
Risk of Developing Euglycemic Diabetic Ketoacidosis (DKA)
Given your family history of type 2 diabetes, it's essential to understand the potential risk factors associated with euglycemic DKA. While there is no direct evidence linking family history to euglycemic DKA, several studies have identified predisposing factors for the development of DKA in patients with type 2 diabetes taking SGLT2 inhibitors 2, 3, 4, 5, 6.
Predisposing Factors for Euglycemic DKA
Some of the identified predisposing factors include:
- Excess alcohol consumption 6
- Female gender 6
- Starvation due to illness or fasting 6
- Withholding the use of SGLT2i for less than 48 hours peri-operatively 6
- Existence of variations in the expression of SGLT2 receptors 6
- Recent major surgery 5
- Decreased or discontinued insulin 5
- Latent autoimmune diabetes of adulthood (LADA) 5
Importance of Awareness and Monitoring
It's crucial to be aware of these potential risk factors and monitor your condition closely if you're taking SGLT2 inhibitors. As noted in the studies, euglycemic DKA can have a latent onset with unspecific symptomatology, making it essential to promptly diagnose and manage the condition to prevent serious life-threatening complications 2, 3, 4.
Key Considerations
When considering your risk of developing euglycemic DKA, keep in mind that:
- The risk of euglycemic DKA associated with SGLT2 inhibitors remains relatively low 3
- Understanding precipitating factors for SGLT2i-related DKA can help providers better identify patients at risk for development of DKA 5
- Patients should be advised on "sick day rules" and withhold the medication for the duration of the intercurrent illness if they become unwell while on an SGLT2i 6