Life-Threatening Complications Related to Delayed Diagnosis of Euglycemic Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter-2 Inhibitors: A Report of 2 Cases

BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are widely used owing to their effective glycemic control and protective effects against heart and kidney failure. Euglycemic diabetic ketoacidosis (eu-DKA) is a complication of treatment with SGLT2is. Eu-DKA often leads to delayed diagnosis and results in life-threatening complications. We report 2 critical cases of SGLT2i-associated eu-DKA. CASE REPORT Case 1 was 52-year-old woman with unstable angina scheduled for elective coronary artery bypass grafting surgery. Preoperatively, she underwent tooth extraction which led to poor food intake because of pain. Three days before surgery, the patient had SGLT2i-associated eu-DKA and myocardial infraction, requiring percutaneous coronary intervention and peripheral venoarterial extracorporeal membrane oxygenation. The patient had taken SGLT2i until the morning of admission to the intensive care unit. Case 2 was a 76-year-old woman experiencing SGLT2i-associated eu-DKA and sinus arrest, necessitating a temporary pacemaker, followed by elective gastrojejunal bypass surgery. The SGLT2i was discontinued the day before surgery. On day 3 following surgery, the patient's metabolic acidosis improved, and sinus arrest resolved. CONCLUSIONS Precipitating factors of eu-DKA (caloric restriction and surgical stress) and delay in diagnosis because of a lack of evidence of hyperglycemia could contribute to the development and worsening of life-threatening complications. This reiterates the importance of reviewing ongoing medications of patients with diabetes and considering eu-DKA as a differential diagnosis for patients with high anion gap metabolic acidosis to ensure early intervention. SGLT2i-associated DKA likely develops perioperatively; therefore, clinicians should pay attention to the discontinuation period of SGLT2i before any surgical intervention.