From the Guidelines
Euglycemic diabetic ketoacidosis (eDKA) presents with the classic symptoms of DKA but with normal or only mildly elevated blood glucose levels (typically <250 mg/dL). Patients commonly experience nausea, vomiting, abdominal pain, excessive thirst, frequent urination, fatigue, and confusion. Physical examination may reveal Kussmaul breathing (deep, rapid breathing), a fruity breath odor from acetone, signs of dehydration including dry mucous membranes and reduced skin turgor, and tachycardia. Laboratory findings typically show metabolic acidosis with an elevated anion gap, positive serum and urine ketones, low bicarbonate levels (<18 mEq/L), and an elevated serum beta-hydroxybutyrate. eDKA is most commonly associated with SGLT2 inhibitor use (medications like empagliflozin, dapagliflozin, and canagliflozin), but can also occur during pregnancy, starvation, alcohol consumption, or with reduced carbohydrate intake. The condition is particularly dangerous because the absence of significant hyperglycemia may delay diagnosis, as clinicians might not immediately consider DKA in a patient with near-normal glucose levels.
Key Clinical Presentations
- Nausea and vomiting
- Abdominal pain
- Excessive thirst and frequent urination
- Fatigue and confusion
- Kussmaul breathing and fruity breath odor
- Signs of dehydration
- Metabolic acidosis with elevated anion gap
- Positive serum and urine ketones
- Low bicarbonate levels and elevated serum beta-hydroxybutyrate
Treatment Approach
Treatment follows standard DKA protocols including IV fluids, insulin therapy, and electrolyte replacement, with careful monitoring of glucose levels to prevent hypoglycemia, as recommended by recent guidelines 1. The use of bicarbonate in patients with DKA is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1. Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the Research
Clinical Presentations of Euglycemic Diabetic Ketoacidosis (DKA)
Euglycemic DKA is a rare complication of diabetes mellitus characterized by metabolic acidosis, ketosis, and blood glucose levels < 250 mg/dL 2, 3, 4. The clinical presentations of euglycemic DKA may include:
- Malaise, fatigue, nausea, and vomiting 2
- Hair loss, numbness, and tingling sensation in the fingertips 2
- Tachycardia and high anion-gap metabolic acidosis 2
- Polyuria and polydipsia, followed by nausea, vomiting, abdominal pain, weight loss, severe fatigue, dyspnea, and preceding febrile illness 5
- Ketosis, with high ketone levels in urine and blood 2, 4
Diagnostic Challenges
Euglycemic DKA poses a challenge to physicians, as patients presenting with normal blood glucose levels in ketoacidosis may be overlooked, leading to a delay in appropriate management strategies 3, 4. A high clinical suspicion is warranted, and other diagnoses ruled out. Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels 4.
Etiology and Pathophysiology
The possible etiology of euglycemic DKA includes: