What is the diagnosis and management for a 53‑year‑old woman with uncontrolled diabetes (random glucose 386 mg/dL) on dapagliflozin and insulin, presenting with palpitations, weakness, supraventricular tachycardia (heart rate 181 bpm) converted with adenosine, mild troponin I elevation, hypoxemia (PaO₂ 66 mm Hg) with infiltrates on chest X‑ray, a non‑healing left foot ulcer, elevated TSH with normal free T₃/T₄, and acute kidney injury (creatinine 126.9 µmol/L)?

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Last updated: October 3, 2026 • View editorial policy

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Diagnosis and Management

This patient has euglycemic diabetic ketoacidosis (euDKA) triggered by dapagliflozin in the setting of acute illness (pneumonia), and you must immediately discontinue dapagliflozin and initiate DKA management protocols while addressing the multiple concurrent acute conditions.

Primary Diagnosis: Euglycemic Diabetic Ketoacidosis (euDKA)

The clinical picture strongly suggests euDKA despite the blood glucose of 386 mg/dL (which is elevated but not markedly so for typical DKA). The constellation of:

  • SGLT2 inhibitor use (dapagliflozin)
  • Acute illness with poor oral intake (suggested by weakness)
  • Non-healing wound (metabolic stress)
  • Pneumonia with hypoxemia (acute stressor)

These factors create the perfect storm for euDKA 1. The FDA labeling explicitly warns that dapagliflozin can cause ketoacidosis that may be life-threatening, and this can occur even with blood glucose less than 250 mg/dL 1. Multiple case reports confirm euDKA occurring within days to weeks of SGLT2 inhibitor initiation, particularly during acute illness 2, 3, 4.

Concurrent Diagnoses

  1. Community-acquired pneumonia - Hypoxemia (PaO₂ 66.2 mmHg) with infiltrates on chest X-ray
  2. Acute kidney injury - Creatinine 126.9 µmol/L (approximately 1.4 mg/dL), likely multifactorial from volume depletion and infection
  3. Diabetic foot infection - Non-healing left foot wound requiring urgent evaluation
  4. Subclinical hypothyroidism - Elevated TSH with normal free T3/T4
  5. Type 2 demand ischemia - Mild troponin elevation in setting of SVT and acute illness

Immediate Management Algorithm

Step 1: Discontinue Dapagliflozin Immediately

Stop dapagliflozin now 1. The FDA labeling is unequivocal: "Stop taking DAPAGLIFLOZIN TABLETS and call your healthcare provider or get medical help right away" if ketoacidosis is suspected 1. Do not restart until metabolically stable.

Step 2: Confirm DKA and Assess Severity

  • Check arterial or venous blood gas immediately
  • Measure serum beta-hydroxybutyrate or urine ketones
  • Calculate anion gap
  • Check serum osmolality

Critical point: Do not be falsely reassured by glucose of 386 mg/dL. EuDKA is defined by ketoacidosis with glucose typically <250 mg/dL, but can occur at higher levels 2, 3, 4.

Step 3: Initiate DKA Protocol per ADA Guidelines

Following the 2025 ADA hospital care guidelines 5:

Fluid resuscitation:

  • Start 0.9% NaCl at clinically appropriate rate
  • Aim to replace 50% of estimated fluid deficit in first 8-12 hours
  • Monitor for volume depletion complications given acute kidney injury 1

Insulin therapy:

  • Start 0.1 units/kg/hour IV regular insulin infusion (or 0.05 units/kg/hour if mild DKA)
  • Continue insulin infusion even when glucose normalizes by adding dextrose-containing fluids
  • Target glucose 150-200 mg/dL until ketoacidosis resolves 5

Potassium management:

  • Check potassium before starting insulin
  • If K+ <3.3 mmol/L: hold insulin and give potassium
  • If K+ 3.3-5.0 mmol/L: add 20-30 mEq K+ per liter of IV fluid
  • Monitor every 2 hours initially 5

Resolution criteria:

  • Anion gap <12 mmol/L
  • Serum bicarbonate ≥15 mmol/L
  • Venous pH >7.3
  • Beta-hydroxybutyrate <0.6 mmol/L 5

Step 4: Treat Pneumonia Aggressively

  • Obtain blood cultures before antibiotics
  • Start empiric broad-spectrum antibiotics for community-acquired pneumonia
  • Provide supplemental oxygen to maintain SpO₂ >90%
  • Consider ICU admission given hypoxemia and metabolic decompensation

Step 5: Evaluate and Treat Diabetic Foot Infection

Per IWGDF/IDSA 2023 guidelines 6:

  • Perform urgent wound assessment and classify infection severity
  • Obtain deep tissue culture or bone biopsy if osteomyelitis suspected
  • Start empiric broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobes
  • Arrange urgent surgical consultation for debridement if moderate-severe infection
  • Ensure pressure off-loading
  • Vascular assessment for peripheral arterial disease

Critical caveat: The guideline emphasizes that focusing only on infection without addressing metabolic control, wound care, and vascular status greatly increases treatment failure 6.

Step 6: Address Cardiac Issues

  • The SVT has converted, but mild troponin elevation suggests type 2 MI from demand ischemia
  • Continue cardiac monitoring
  • Optimize volume status carefully given both DKA and cardiac stress
  • Consider beta-blocker once hemodynamically stable to prevent SVT recurrence

Step 7: Manage Acute Kidney Injury

  • The elevated creatinine is likely from volume depletion exacerbated by dapagliflozin 1
  • Aggressive fluid resuscitation for DKA should improve renal function
  • Monitor creatinine every 2-4 hours initially
  • Adjust insulin dosing if renal function worsens

Step 8: Address Subclinical Hypothyroidism

  • TSH 11 with normal free T3/T4 is subclinical hypothyroidism
  • Do not start thyroid replacement acutely during this critical illness
  • Reassess thyroid function after recovery (4-6 weeks)
  • Consider treatment if TSH remains >10 mIU/L

Ongoing Diabetes Management After Recovery

Do not restart dapagliflozin - The risk of recurrent euDKA is too high, especially with recurrent acute illnesses likely given the diabetic foot infection 1, 3.

Alternative regimen:

  • Continue basal insulin (adjust dose based on requirements during hospitalization)
  • Add prandial rapid-acting insulin
  • Consider GLP-1 receptor agonist once eating normally (safer metabolic profile)
  • Optimize metformin if renal function permits

Key Pitfalls to Avoid

  1. Missing euDKA diagnosis because glucose isn't "high enough" - Check ketones in any SGLT2 inhibitor patient with nausea, vomiting, or weakness 3, 4

  2. Restarting dapagliflozin too soon - FDA warns to resume only when "clinically stable and has resumed oral intake" 1. Given this patient's multiple comorbidities, consider permanent discontinuation.

  3. Undertreating the foot infection - This requires aggressive multidisciplinary management, not just antibiotics 6

  4. Stopping insulin infusion prematurely - Continue until anion gap closes and ketones clear, even if glucose normalizes 5

  5. Inadequate potassium replacement - Insulin drives potassium intracellularly; aggressive monitoring and replacement prevent life-threatening hypokalemia 5

  6. Ignoring volume status - SGLT2 inhibitors cause volume depletion; this patient likely has significant intravascular depletion contributing to AKI and hypotension risk 1

References

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