Immediate Management: Euglycemic Diabetic Ketoacidosis (DKA) with Possible Appendicitis
This patient requires immediate discontinuation of canagliflozin, aggressive treatment for euglycemic DKA with intravenous insulin and fluid resuscitation, followed by urgent surgical consultation for appendicitis once metabolic stabilization is achieved.
Critical Recognition: SGLT2 Inhibitor-Induced Euglycemic DKA
This presentation is classic for canagliflozin (Invokana)-induced euglycemic DKA, not typical hyperglycemic DKA:
The metabolic acidosis (pH 7.24, bicarbonate 17, anion gap 15, base excess -9) with normal-range glucose represents euglycemic DKA, a life-threatening complication of SGLT2 inhibitors that is easily missed because blood glucose is not markedly elevated 1, 2, 3.
Precipitating factors are present: reduced oral intake for 5 days, nausea/vomiting (though suppressed by antiemetics), and likely acute appendicitis—all documented triggers for SGLT2i-induced euglycemic DKA 3, 4.
The tachycardia (HR 124) despite appearing "well" reflects compensatory response to metabolic acidosis and volume depletion, common in SGLT2i-associated DKA 1, 4.
Immediate Metabolic Management (Priority #1)
Stop Canagliflozin Permanently
- Discontinue canagliflozin immediately and permanently—this is the offending agent causing euglycemic DKA 1, 2, 3.
Confirm Ketoacidosis
- Measure serum beta-hydroxybutyrate and urine ketones immediately to confirm ketoacidosis, as these are essential for diagnosis 1, 2, 5.
- The anion gap of 15 with severe metabolic acidosis strongly suggests ketoacidosis in this clinical context 1, 3.
Initiate DKA Treatment Protocol
Start intravenous insulin infusion immediately (typically 0.1 units/kg/hour) even though glucose is not markedly elevated 1, 2, 3.
Begin aggressive intravenous fluid resuscitation with isotonic saline to correct volume depletion caused by SGLT2i-induced glucosuria and reduced oral intake 6, 1, 4.
Add dextrose-containing fluids once glucose approaches 200-250 mg/dL to prevent hypoglycemia while continuing insulin to clear ketones 1, 2.
Monitor and aggressively replace potassium, as insulin therapy will drive potassium intracellularly despite normal baseline K+ 3.8 1, 2.
Serial arterial blood gases every 2-4 hours to monitor resolution of acidosis and guide therapy 6, 1.
ICU-Level Monitoring Required
- Admit to intensive care unit for continuous monitoring, as 61.5% of SGLT2i-induced euglycemic DKA cases require ICU care 3.
Surgical Decision-Making (Priority #2)
Timing of Appendectomy
Delay surgical intervention for appendicitis until metabolic acidosis is corrected (pH >7.2, bicarbonate >15, anion gap normalized) 6.
The CT findings show "very early acute appendicitis" without perforation or abscess, allowing time for metabolic stabilization before surgery 6.
Target 2-6 hours of resuscitation before proceeding to surgery to prevent hemodynamic instability on induction of anesthesia 6.
Surgical Approach Once Stabilized
Proceed with laparoscopic appendectomy once pH >7.2 and patient is hemodynamically stable with adequate urine output and normalized lactate 6.
The patient's vital stability (BP 135/84, lactate 1.3) and lack of peritonitis suggests this is not perforated appendicitis requiring emergency surgery 6.
Critical Pitfalls to Avoid
Don't Miss the Diagnosis
Euglycemic DKA is easily missed because glucose is not markedly elevated—the key is recognizing the metabolic acidosis pattern in a patient on SGLT2 inhibitors with nausea, vomiting, and reduced oral intake 1, 3.
Do not attribute the acidosis solely to appendicitis or sepsis without checking ketones—the anion gap acidosis with normal lactate (1.3) points to ketoacidosis, not lactic acidosis 1, 3.
Don't Rush to Surgery
Operating on a patient with severe metabolic acidosis (pH 7.24) significantly increases perioperative morbidity and mortality 6.
The "lethal triad" of acidosis, hypothermia, and coagulopathy must be avoided—correct acidosis first unless there is frank perforation with peritonitis 6.
Don't Use Bicarbonate Inappropriately
Bicarbonate is NOT recommended for DKA unless pH <7.0, as insulin therapy will correct the acidosis by clearing ketones 6.
The pH of 7.24 does not meet criteria for bicarbonate administration in ketoacidosis 6.
Monitoring Endpoints
- Anion gap closure (target <12) 1, 2
- Serum ketone clearance (beta-hydroxybutyrate <0.6 mmol/L) 1, 2
- pH normalization (>7.35) 6, 1
- Bicarbonate improvement (>18-20 mEq/L) 1, 2
- Clinical improvement: resolution of nausea, improved mental status, hemodynamic stability 1, 3
Prognosis and Follow-Up
Mortality from SGLT2i-induced euglycemic DKA is only 2.4% when recognized and treated appropriately 3.
Never restart canagliflozin—switch to alternative diabetes medication after discharge 1, 2, 3.
Patient education is critical: inform about this rare but serious complication and ensure all future providers know about this adverse reaction 3.