Symptoms of Euglycemic Diabetic Ketoacidosis (eDKA)
Euglycemic diabetic ketoacidosis presents with the classic symptoms of DKA but with blood glucose levels below 200 mg/dL, making it a dangerous and easily missed diagnosis that requires high clinical suspicion. 1, 2
Clinical Presentation
Cardinal Symptoms
- Malaise and fatigue
- Nausea and vomiting
- Abdominal pain (can be severe, sometimes mimicking acute peritonitis) 3
- Dyspnea or Kussmaul respirations (deep, rapid breathing)
- Dehydration
- Weakness
Other Common Symptoms
- Altered mental status
- Fruity breath odor (acetone smell)
- Polyuria
- Polydipsia
- Weight loss
Laboratory Findings
- Blood glucose <200 mg/dL (defining characteristic)
- Elevated anion gap metabolic acidosis (pH <7.3)
- Serum bicarbonate <18 mEq/L
- Positive serum and/or urine ketones
- Elevated serum β-hydroxybutyrate levels
Risk Factors and Precipitating Conditions
SGLT2 Inhibitor Use
SGLT2 inhibitors (dapagliflozin, canagliflozin, empagliflozin) are strongly associated with euglycemic DKA 1, 4. The FDA label for dapagliflozin specifically warns about this risk.
Common Triggers
- Intercurrent illness/infection 1
- Reduced food and fluid intake
- Reduced insulin doses
- Alcohol consumption
- Surgery or invasive procedures
- Ketogenic or low-carbohydrate diets 5
- Insulin pump failure 6
- Starvation or fasting
Diagnostic Challenges
Euglycemic DKA is frequently missed in the emergency department due to:
- Normal or only mildly elevated blood glucose levels
- Nonspecific symptoms that may be attributed to other conditions
- Failure to check for ketones when blood glucose is not markedly elevated
Clinical Course and Management
The clinical course of euglycemic DKA typically involves:
- Initial presentation with nonspecific symptoms
- Laboratory confirmation showing metabolic acidosis with normal/near-normal glucose
- Treatment requiring:
- Intravenous fluids (often with dextrose to maintain glucose levels)
- Insulin therapy (may need to be delayed until glucose rises above 250 mg/dL) 5
- Electrolyte monitoring and replacement
- Addressing underlying triggers
Prevention Strategies
For patients on SGLT2 inhibitors:
- Discontinue the medication 3-4 days before elective procedures 1
- Seek immediate medical attention if symptoms develop
- Monitor ketones during illness, regardless of blood glucose levels
- Maintain adequate hydration and carbohydrate intake during illness
Key Differences from Classic DKA
| Feature | Classic DKA | Euglycemic DKA |
|---|---|---|
| Blood glucose | >250 mg/dL | <200 mg/dL |
| Diagnosis | More straightforward | Often delayed or missed |
| Treatment | Standard DKA protocol | Modified protocol with glucose administration |
Clinicians should maintain a high index of suspicion for euglycemic DKA in any patient taking SGLT2 inhibitors who presents with nonspecific symptoms like nausea, vomiting, and abdominal pain, even if blood glucose levels are normal or only mildly elevated 7, 8.