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Euglycemic Diabetic Ketoacidosis (DKA) & SGLT-2 inhibitors

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Introduction
Euglycemic DKA is a rare complication of SGLT-2 inhibitors in people with type 2 diabetes. It is more likely to occur if your patient is:

  • Fasting
  • Acutely unwell
  • Septic
  • Following a carbohydrate-restricted diet
  • Following missed insulin doses if patient is also taking insulin

It presents with a metabolic acidosis and ketonaemia, but the glucose is either normal or mildly elevated. It is treated with the same protocol as a patient with DKA.

Clinical presentation:

  • Abdominal pain
  • Fatigue or altered level of consciousness
  • Thirst, dehydration
  • Fever if underlying trigger is sepsis

Diagnostic criteria

Biochemical diagnosis is based on venous blood result:

  • pH <7.30
  • Bicarbonate < 18 mmol/L
  • Ketones >3.0mmol/L
  • Osmolality 250 – 320 mOsm/kg
  • Dehydration is moderate

Management

Follow the same management recommendations as for Diabetic Ketoacidosis (DKA) and the SGLT-2 I should not be restarted on discharge.

  1. Intravenous fluids
    • 1st bag: 0.9% Normal Saline resuscitation @ 500ml per hour
    • 2nd bag: 0.9% Normal Saline @ 250ml per hour
    • 3rd bag: 0.9% Normal Saline @ 125 ml per hour
  2. Potassium replacement 
    Give intravenous potassium infusion if serum K+ is below 5 mmol/L:
    Serum potassium IV potassium
    <3.5mmol/L 2 x 10 mmol/L over 1 hour
    3.5 – 5 mmol/L 10 mmol/L over 1 hour
    >5 mmol/L Nil potassium needed
  3. Dextrose infusion
    • Switches off the ketosis
    • Give Dextrose 10% at 125ml per hour in a side-line
    • Give oral hydration with glucose-containing fluid eg. Hydralyte, weak cordial
    • If patient is able to eat without vomiting, give low-GI carbohydrate eg. slice of bread
  4. Insulin infusion
    • Starting infusion rate of 0.5 units per hour with Dextrose infusion
    • 1-hourly glucose monitoring
    • Aims to reverse ketosis
  5. Investigate underlying cause
    • Bloods for CRP, Troponin, blood cultures, lipase
    • Urine for MCS
    • Chest x-ray
    • Lumbar puncture if indicated
    • 12-lead ECG
  6. Monitoring
    • 1-hourly capillary blood glucose
    • 2-hourly capillary blood ketones
    • 1-hourly fluid balance
    • Venous blood at 2 hours, 4 hours, 8 hours, 12 hours for:
      1. pH
      2. Bicarbonate
      3. Osmolality
  7. Non-diabetic care
    • Thromboprophylaxis
    • Pantoprazole 20 mg daily to prevent gastritis
    • Aperients
    • Pressure care