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It is characterized by the triad of hyperglycemia, metabolic acidosis and ketosis. Hyperglycemia is considered a key criterion in the diagnosis of DKA. However, rarely, blood glucose levels can be within normal range.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> This entity is known as euglycemic DKA.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case report of an euglycemic DKA episode in a patient with known type 1 diabetes mellitus, triggered by a sodium glucose transporter 2 (SGLT2).</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a 51-year-old male patient with a history of type 2 diabetes mellitus with poor glycemic control (HbA1 11%) under treatment with a SGLT2 (empagliflozin). He went to the Emergency Department of our hospital for recent asthenia, hyporexia, nausea and malaise plus decreased level of consciousness on the day of admission. Upon arrival in the Emergency Department, he presented a poor general condition with altered level of consciousness, dehydrated and poorly perfused. He was tachycardic and tachypneic with shallow breathing and no other changes during examination. He was referred to the Intensive Care Unit of our hospital. The first blood test showed glucose 185<span class="elsevierStyleHsp" style=""></span>mg/dl, ketones 6.2<span class="elsevierStyleHsp" style=""></span>mmol/l, urea 164<span class="elsevierStyleHsp" style=""></span>mg/dl, creatinine 1.62<span class="elsevierStyleHsp" style=""></span>mg/dl, PCR 19.2<span class="elsevierStyleHsp" style=""></span>mg/dl, PCT 6.15<span class="elsevierStyleHsp" style=""></span>ng/ml, with normal electrolyte levels and normal liver function tests. The blood count showed 14,000 leukocytes, hemoglobin 11.9<span class="elsevierStyleHsp" style=""></span>g/dl and platelets 195,000, with normal coagulation profile. Arterial-blood gas test showed a severe metabolic acidosis with pH 7.08, bicarbonate levels 5.3 and base excess by −26,200. The first hours of hospital admission the patient's condition worsened despite the administration of intensive fluid therapy and sodium bicarbonate, requiring orotracheal intubation, sedoanalgesia and connection to mechanical ventilation as well as renal replacement therapy (continuous veno-venous hemodiafiltration). Euglycemic ketoacidosis was suspected. Therefore, insulin perfusion was also started, being necessary for 3 days until the normalization of blood ketones, keeping normal blood glucose levels. After onset of renal replacement therapy, the patient evolved favorably and the acid–base balance parameters went back to normal. Therefore, the patient could be extubated and the hemofilter was removed at 24<span class="elsevierStyleHsp" style=""></span>h. On the fourth day he was discharged after withdrawal of insulin perfusion and normalization of the ketones.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Euglycemic DKA is a rare entity, which occurs with blood glucose levels below 200<span class="elsevierStyleHsp" style=""></span>mg/dl. Potential etiologies of euglycemic DKA include recent use of insulin, poor caloric intake, alcohol consumption, chronic liver disease, and glycogen storage disorders. The recent use of SGLT2 inhibitors has become a potential mechanism of euglycemic DKA.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">SGLT2 inhibitors reduce blood glucose levels, increase urinary glucose excretion and decrease insulin secretion from pancreatic B cells. This results in a decreased lipolysis and the stimulation of free fatty acids, which are turned into ketones in the liver. On the other hand, SGLT2 inhibitors are also associated with an increased glucagon production. The lowering of the insulin–glucagon ratio further stimulates lipolysis and increases the circulation of free fatty acids and lipid oxygenation. In addition, SGLT2 receptors have been identified in pancreatic cells where their inhibition promotes the secretion of glucagon, which helps increase the production of ketones.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Euglycemic DKA poses a challenge to physicians, since patients with normal blood glucose levels in ketoacidosis may be underestimated, leading to a delay in treatment approaches. Despite normoglycemia, ketoacidosis remains a medical emergency and should be treated quickly and appropriately.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Thus, in early detection of ketosis when the first symptoms occur (malaise, nausea, and/or vomiting) the recommendations should be to temporarily withdraw SGLT2 inhibitors, hydration, frequent consumption of carbohydrates and administration of complete doses of insulin to prevent progression to DKA. In fact, in this context, the temporary withdrawal of these drugs during acute illness or surgery are reasonable.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand, diabetic patients assume that their condition is not related to diabetes mellitus if their blood glucose levels are not significantly increased. However, patients taking SGLT2 inhibitors should be trained to test their ketones in urine, if they present any symptoms, regardless of low or normal blood glucose levels.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Castro A, Ortiz Lasa M, Jiménez Alfonso A. Cetoacidosis diabética euglucémica. Med Clin (Barc). 2019;152:416–417.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyperglycemic crises in adult patients with diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.E. Kitabchi" 1 => "G.E. Umpierrez" 2 => "J.M. Miles" 3 => "J.N. Fisher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2337/dc09-9032" "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2009" "volumen" => "32" "paginaInicial" => "1335" "paginaFinal" => "1343" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19564476" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Euglycemic diabetic ketoacidosis: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Modi" 1 => "A. Agrawal" 2 => "F. Morgan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2174/1573399812666160421121307" "Revista" => array:6 [ "tituloSerie" => "Curr Diabetes Rev" "fecha" => "2017" "volumen" => "13" "paginaInicial" => "315" "paginaFinal" => "321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27097605" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Euglycemic diabetic ketoacidosis with elevated acetone in a patient taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.J. Andrews" 1 => "R.D. Cox" 2 => "C. Parker" 3 => "J. Kolb" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emerg Med J" "fecha" => "2017" "volumen" => "52" "paginaInicial" => "223" "paginaFinal" => "226" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SGLT2 inhibitor-associated euglycemic diabetic ketoacidosis: a South Australian clinical case series and Australian spontaneous Q4 adverse event notifications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Meyer" 1 => "G. Gabb" 2 => "D. Jesudason" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2337/dc17-1721" "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2018" "volumen" => "41" "paginaInicial" => "e47" "paginaFinal" => "e49" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29440112" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Rosenstock" 1 => "E. Ferrannini" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2337/dc15-1380" "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2015" "volumen" => "38" "paginaInicial" => "1638" "paginaFinal" => "1642" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26294774" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000010/v1_201905220844/S2387020619301512/v1_201905220844/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000010/v1_201905220844/S2387020619301512/v1_201905220844/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619301512?idApp=UINPBA00004N" ]
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Scientific letter
Euglycemic diabetic ketoacidosis
Cetoacidosis diabética euglucémica
Alejandro González-Castro, María Ortiz Lasa
, Andrés Jiménez Alfonso
Corresponding author
Hospital Universitario Marqués de Valdecilla, Santander, Spain