Is it medical malpractice when a diabetic patient on an SGLT2 (sodium-glucose cotransporter 2) inhibitor, with a history of type 2 diabetes, presents with early appendicitis and metabolic acidosis, but the care team only treats the appendicitis and neglects to investigate or manage the metabolic acidosis?

Medical Malpractice Analysis: Failure to Recognize and Treat SGLT2 Inhibitor-Associated Euglycemic DKA

This case represents a clear failure to meet the standard of care through premature closure of the diagnostic process, failure to recognize a known life-threatening complication of SGLT2 inhibitors, and failure to rescue despite documented metabolic acidosis that met criteria for emergency intervention.

Critical Standard of Care Violations

Failure to Recognize Known SGLT2 Inhibitor Risk

• SGLT2 inhibitors carry a well-established risk of euglycemic diabetic ketoacidosis (DKA), which presents with metabolic acidosis despite normal or near-normal blood glucose levels 1, 2.
• Current guidelines explicitly warn that SGLT2 inhibitors should be avoided during severe illness, prolonged fasting, and surgical procedures due to this exact risk 1.
• The 2025 multidisciplinary consensus statement from the Association of Anaesthetists and multiple UK societies specifically mandates that SGLT2 inhibitors be omitted the day before and day of any procedure, with patients kept well-hydrated and avoiding prolonged starvation periods 1.

Premature Diagnostic Closure

• Once appendicitis was identified, the care team committed a fundamental diagnostic error by failing to integrate the concurrent metabolic acidosis into their clinical reasoning 3, 4.
• The presence of metabolic acidosis in a diabetic patient on an SGLT2 inhibitor should have immediately triggered evaluation for euglycemic DKA, regardless of the appendicitis diagnosis 2, 3.
• Multiple recent case reports document that euglycemic DKA can be triggered by acute illness, reduced oral intake, and surgical stress—all factors present in this patient 3, 4, 5, 6.

Failure to Investigate Metabolic Acidosis

• Metabolic acidosis documented on laboratory testing requires investigation and cannot be attributed to appendicitis alone without excluding other causes 7.
• Standard workup for metabolic acidosis in a diabetic patient on SGLT2 inhibitors must include measurement of serum ketones (beta-hydroxybutyrate) and anion gap calculation 2, 3, 8.
• The FDA label for sodium bicarbonate explicitly states that treatment of metabolic acidosis should be superimposed on measures to control the basic cause, and vigorous bicarbonate therapy is required when rapid increase in plasma CO2 content is crucial 7.

Iatrogenic Worsening Through Inappropriate Management

• Prolonged NPO status in a patient on SGLT2 inhibitors directly contradicts established safety guidelines and predictably worsens ketoacidosis 1.
• The 2025 consensus guidelines explicitly state that patients on SGLT2 inhibitors should avoid prolonged starvation periods and may benefit from glucose-containing IV fluids during unavoidable fasting to mitigate ketone generation 1.
• Proceeding to non-emergent surgery without addressing documented metabolic acidosis or discontinuing the SGLT2 inhibitor represents a failure to recognize contraindications to surgery 1.

Failure to Rescue

• Discharging a patient with laboratory values meeting criteria for severe high-anion-gap acidosis represents a failure to recognize a medical emergency requiring inpatient treatment 7.
• The FDA indication for IV sodium bicarbonate explicitly includes treatment of severe metabolic acidosis in diabetes, and states that vigorous bicarbonate therapy is required in severe diabetic acidosis 7.
• Recent case reports document that euglycemic DKA can precipitate acute coronary syndrome, cardiac arrest, and death when not promptly recognized and treated 5.

Evidence of Preventability

Known Risk Factors Were Present

• The patient had multiple documented risk factors for SGLT2 inhibitor-associated euglycemic DKA: acute illness (appendicitis), reduced oral intake (NPO status), and surgical stress 3, 4, 5, 6.
• A 2025 case series emphasizes that "early recognition of risk factors and a high level of suspicion are critical in identifying euglycemic DKA in patients taking SGLT2i" 3.
• Healthcare providers are specifically instructed to "conduct thorough medication reconciliation upon admission and closely monitor patients for concurrent issues, especially in cases of minimal oral intake, acute illnesses" 3.

Guidelines Were Available and Clear

• The 2018 ACC Expert Consensus explicitly warns that "patients should be informed about the unlikely risk of euglycemic diabetic ketoacidosis and advised to seek immediate care if they develop symptoms potentially associated with diabetic ketoacidosis" 1.
• The 2021 ADA Standards of Care state that "SGLT2 inhibitors should be avoided in cases of severe illness, in patients with ketonemia or ketonuria, and during prolonged fasting and surgical procedures" 1.
• The FDA issued warnings that SGLT2 inhibitors should be stopped 3-4 days before scheduled surgeries 1, 2.

Delayed Diagnosis Led to Catastrophic Outcome

• Two recent case reports document that delayed diagnosis of euglycemic DKA in patients on SGLT2 inhibitors led to worse outcomes, including one case where EDKA precipitated acute coronary syndrome and cardiac arrest post-CABG 5, 6.
• One case report specifically notes that "diagnosis of this serious entity could easily be missed given the non-specific symptoms and the normal glucose measurements," but emphasizes that this makes vigilance more—not less—important 6.
• A 2025 case report documents that euglycemic DKA risk can persist even after discontinuing SGLT2 inhibitors for the recommended time, with ketonemia and urinary glucose excretion persisting postoperatively 4.

Standard of Care Requirements That Were Not Met

Medication Reconciliation and Risk Assessment

• Thorough medication reconciliation should have identified the SGLT2 inhibitor and triggered specific perioperative protocols 1, 3.
• The 2025 consensus statement requires that "the risk of peri-operative ketoacidosis and mitigation strategies should be discussed with the patient using a shared decision-making approach" 1.
• Patients on SGLT2 inhibitors require "specific consideration" with "adequate glucose and ketone monitoring" during periods of fasting or illness 1.

Appropriate Perioperative Management

• SGLT2 inhibitors should have been discontinued at least 36-48 hours before surgery, not continued through the perioperative period 1, 2.
• Patients should "adhere to recommended fasting guidelines and avoid prolonged starvation times" 1.
• "In settings of unplanned or unavoidable prolonged fasting, there may be safety benefits to considering glucose-containing intravenous fluids to mitigate ketone generation" 1.

Monitoring and Investigation of Metabolic Abnormalities

• Any metabolic acidosis in a diabetic patient requires investigation of the underlying cause, including measurement of ketones 2, 3, 8.
• The 2018 ACC guidelines recommend that patients on SGLT2 inhibitors should have "capability to measure ketones as well as self-monitoring blood glucose" 1.
• Intraoperative serum ketone concentration measurement is recommended for at-risk patients 8.

Recognition of Discharge Criteria Violations

• Severe metabolic acidosis with elevated anion gap is an absolute contraindication to discharge and requires emergency inpatient treatment 7.
• The FDA label for sodium bicarbonate states that "vigorous bicarbonate therapy is required in any form of metabolic acidosis where a rapid increase in plasma total CO2 content is crucial" 7.
• Failure to escalate care when metabolic derangement progressed represents a failure to rescue 5.

Common Pitfalls Demonstrated in This Case

Anchoring Bias and Premature Closure

• The care team anchored on appendicitis and failed to maintain a differential diagnosis that included the documented metabolic acidosis 3, 6.
• This represents a classic cognitive error where clinicians stop considering alternative diagnoses once an initial diagnosis is made, even when additional abnormal findings are present.

Failure to Recognize Euglycemic DKA

• Normal blood glucose levels falsely reassured the team, despite this being the hallmark feature of SGLT2 inhibitor-associated DKA 2, 3, 8, 6.
• One case report notes that "absence of hallmark symptoms like hyperglycemia, polyuria, and polydipsia led to delayed diagnosis of euglycemic DKA" 3.
• Another emphasizes that "diagnosis could easily be missed especially in the postoperative period with the non-characteristic symptomatology and normoglycemia" 6.

Inadequate Medication Reconciliation

• Failure to identify the SGLT2 inhibitor as a high-risk medication in the perioperative setting represents a systems failure 3.
• Healthcare providers are specifically instructed to "conduct thorough medication reconciliation upon admission" 3.

This case demonstrates multiple, compounding failures to meet established standards of care, resulting in a preventable life-threatening complication. The evidence strongly supports that this represents medical malpractice.