Can a patient with euglycemic (normal blood sugar levels) diabetic ketoacidosis (DKA) present with normal blood sugar levels?

Euglycemic Diabetic Ketoacidosis: Presentation with Normal Blood Sugar

Yes, patients with euglycemic diabetic ketoacidosis (DKA) can present with normal blood glucose levels, defined as glucose <200 mg/dL (11.1 mmol/L), while still exhibiting the metabolic acidosis and ketosis characteristic of DKA. 1

Diagnostic Criteria for Euglycemic DKA

Euglycemic DKA is diagnosed when a patient presents with:

• Blood glucose <200 mg/dL (11.1 mmol/L)
• Arterial pH <7.3
• Serum bicarbonate <18 mEq/L
• Presence of ketones in blood or urine 2

This contrasts with classic DKA, which requires blood glucose >250 mg/dL along with the other criteria 1.

Common Precipitating Factors

Several specific conditions can precipitate euglycemic DKA:

1. SGLT2 inhibitor therapy - These medications increase urinary glucose excretion, leading to lower blood glucose levels while ketosis develops 1, 3

2. Pregnancy - Pregnant individuals have increased risk of euglycemic DKA due to altered metabolism 1, 2

3. Reduced food intake/starvation - Carbohydrate restriction with continued insulin use 2, 4

4. Insulin use prior to presentation - Partial treatment that lowers glucose but doesn't fully resolve ketosis 3

5. Alcohol consumption - Can inhibit gluconeogenesis while promoting ketogenesis 5

6. Ketogenic diets - Severe carbohydrate restriction can trigger euglycemic DKA, especially in undiagnosed or poorly controlled diabetes 4

Clinical Implications and Pitfalls

The primary danger with euglycemic DKA is delayed diagnosis. Normal glucose levels can mislead clinicians who may not consider DKA in their differential diagnosis 5, 6. This delay in appropriate treatment can increase morbidity and mortality.

Key pitfalls to avoid:

• Overlooking DKA due to normal glucose - Always check ketones and acid-base status in ill diabetic patients regardless of glucose level 6
• Inadequate monitoring of ketone resolution - Focus should be on resolving the metabolic acidosis, not just glucose control 2
• Inappropriate insulin management - Patients with euglycemic DKA have over three times higher risk of hypoglycemia during treatment compared to hyperglycemic DKA patients 3

Management Considerations

Treatment of euglycemic DKA requires modification of standard DKA protocols:

1. Fluid resuscitation - Still essential, typically with 0.9% NaCl at 15-20 mL/kg/hr initially 2

2. Insulin therapy - Must be administered with dextrose-containing fluids to prevent hypoglycemia 4

   • Consider delaying insulin infusion until blood glucose levels increase above 250 mg/dL 4
   • Continue insulin until metabolic acidosis resolves, regardless of glucose levels 2

3. Glucose monitoring - More frequent monitoring (every 1-2 hours) is required due to increased risk of hypoglycemia 2, 3

4. Addressing underlying cause - Identify and treat the precipitating factor (discontinue SGLT2 inhibitors, treat infection, etc.) 2

Clinical Pearls

• In patients on SGLT2 inhibitors presenting with nausea, vomiting, or malaise, check for DKA even with normal glucose levels 1
• Pregnant diabetic patients with nausea/vomiting should have ketones checked regardless of glucose level 1, 2
• Patients following ketogenic diets who develop symptoms like fatigue, nausea, or vomiting should be evaluated for euglycemic DKA 4
• Direct measurement of β-hydroxybutyrate in blood is preferred over urine ketones for monitoring DKA resolution 1

Recognizing that DKA can present with normal glucose levels is critical for timely diagnosis and appropriate management, particularly in high-risk scenarios like SGLT2 inhibitor use, pregnancy, and starvation states.