Can a patient with a blood glucose level of 82 mg/dL still be in diabetic ketoacidosis (DKA) with ketones present in the urine?

Yes, a Patient with a Blood Glucose of 82 mg/dL Can Have Diabetic Ketoacidosis

A patient with a blood glucose level of 82 mg/dL can absolutely have diabetic ketoacidosis (DKA), specifically a variant called euglycemic DKA, especially if they are taking SGLT2 inhibitors or have other risk factors.1, 2

Understanding Euglycemic DKA

Euglycemic DKA is characterized by:

• Metabolic acidosis
• Presence of ketones in blood and urine
• High anion gap
• Blood glucose levels <200 mg/dL (sometimes as low as 75-90 mg/dL)2, 3

Key Risk Factors for Euglycemic DKA

• SGLT2 inhibitor use - These medications increase the risk of DKA in both type 1 and type 2 diabetes by promoting glycosuria while maintaining ketogenesis4, 1
• Prolonged fasting or starvation
• Low carbohydrate diets (<20-30g daily)
• Pregnancy
• Alcohol consumption
• Missed insulin doses
• Illness or infection1

Diagnostic Approach

When evaluating a patient with normal blood glucose but suspected DKA:

1. Measure blood β-hydroxybutyrate (bOHB) - This is the preferred method for diagnosis rather than urine ketones4, 1
2. Check venous blood gases - Look for pH <7.3 and bicarbonate <18 mEq/L
3. Calculate anion gap - An elevated anion gap (>12 mEq/L) supports the diagnosis
4. Evaluate electrolytes - Particularly sodium, potassium, and chloride levels
5. Consider other causes of ketosis with normal glucose:
   • Alcoholic ketoacidosis
   • Starvation ketosis
   • Pregnancy4, 1

Important Clinical Considerations

• Urine ketone tests are inadequate for diagnosis and monitoring of DKA as they primarily detect acetoacetate and acetone, not β-hydroxybutyrate (the predominant ketone in DKA)4
• SGLT2 inhibitors create a unique risk for euglycemic DKA as they promote urinary glucose excretion while maintaining ketogenesis, resulting in ketoacidosis without marked hyperglycemia1, 5
• Case reports document very low glucose levels in euglycemic DKA, with documented cases showing glucose as low as 75 mg/dL2

Management of Euglycemic DKA

The treatment principles are similar to classic DKA but with important differences:

1. Administer glucose-containing IV fluids immediately - Unlike classic DKA, dextrose should be given early to induce endogenous insulin secretion and halt ketogenesis5, 3
2. Provide insulin therapy - Continuous insulin infusion at 0.1 unit/kg/hr is recommended1
3. Correct fluid and electrolyte imbalances
4. Monitor ketones using blood bOHB measurements rather than urine ketones4, 1
5. Continue treatment until DKA resolves - Resolution criteria include glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap <12 mEq/L1

Common Pitfalls to Avoid

• Failing to check for ketones when glucose is normal - This is a critical mistake that can delay diagnosis of euglycemic DKA1
• Relying solely on urine ketones - Blood bOHB measurement is more accurate and preferred4, 1
• Stopping insulin too early - Treatment should continue until ketoacidosis resolves, not just until glucose normalizes1
• Missing the diagnosis due to normal glucose levels - Always consider euglycemic DKA in patients with risk factors (especially SGLT2 inhibitor use) who present with symptoms of DKA despite normal glucose3

In conclusion, the presence of a normal blood glucose level (82 mg/dL) does not exclude the diagnosis of DKA, particularly in patients with risk factors for euglycemic DKA. Proper diagnosis requires assessment of blood ketones, acid-base status, and anion gap, regardless of the blood glucose level.