Background: Diabetic ketoacidosis (DKA) is a serious complication of diabetes seen
commonly in autoimmune Type 1 diabetes mellitus (DM), however patients with Type 2 diabetes are
also at risk. Diabetic ketoacidosis may be precipitated by the catabolic stress of acute illness such as
trauma, surgery, or infections. Recent studies have suggested that sodium-glucose cotransporter-2
(SGLT-2) inhibitors precipitate DKA in Type 2 diabetes. We present a case series of four patients on
SGLT-2 inhibitors who presented with DKA.
Methods: Medical records were reviewed and patients who were admitted with diabetic ketoacidosis
in the last one year at our institute were identified. The charts of such patients were reviewed and we
were able to identify 4 patients who were admitted with DKA and were on SGLT-2 inhibitors at the
time of admission for the management of their diabetes.
Results: The age group of the four patients was between 45-65 years. Interestingly, all four patients
were female. The admission blood glucose levels of these patients ranged from 203 to 400(mg/dl).
The pH at the time of admission was in the acidotic range with anion gap ranging from 19 to 24. Two
of these four patients had symptoms of a localized infection at the time of admission, which was confirmed
by laboratory and radiological evaluation. Three of these patients required management in the
intensive care unit.
Conclusion: Ketoacidosis is a rare but serious side effect of SGLT2 inhibitors. It is being increasingly
reported as these drugs are now commonly being prescribed in the primary care setting. Awareness
that DKA can occur in the setting of relative euglycemia is critical to recognize this life-threatening
complication of diabetes. More research is needed to better understand the underlying pathophysiology
and precipitating factors leading to ketoacidosis in SGLT-2 inhibitor treated patients.