SUN-649 - A Case of Euglycemic Ketoacidosis in an Individual Taking an Sglt2I without Pre-Existing Diabetes Mellitus

Introduction: SGLT2i are often used for management of type 2 diabetes mellitus as well as for cardiac and renal protection. Although euglycemic ketoacidosis (EuKA) is a known risk associated with SGLT2i use, it is underrecognized for SGLT2i use without comorbid diabetes.
Clinical

Case: An 83-year-old male presented to the ED in May 2025 with SOB and weakness. His past medical history was significant for HFrEF, CAD with multiple stents, total RCA occlusion with a planned TAVR, MDD, and bipolar disorder. Notably, he was taking Quetiapine and Empagliflozin at admission without comorbid type 2 diabetes mellitus. Initial labs revealed low serum bicarbonate (16 meq/L), elevated anion gap (26 meq/L), elevated -hydroxybutyrate (BHB) (2.1 mmol/L), mildly elevated blood glucose (115 mg/dL), elevated proBNP (20574.0pg/mL) and mild worsening of chronic renal disease. Venous pH and lactic acid were both within the reference range, and A1c was 4.7%. The significant anion gap metabolic acidosis with normal lactic acid and elevated BHB led to the consult of endocrinology for suspected EuKA. Following the consult the SGLT2i was discontinued, an insulin drip of .02 units/kg/hr was initiated, as well as 100mL/hr of D5W. The patient’s anion gap was closed and acidosis resolved that night following treatment and patient was transferred to the floor. The following morning the patient returned to the ICU as the anion gap had reopened and the patient had reentered EuKA prompting the reinitiation of an insulin drip. The next day the patient suffered increased pulmonary congestion and hypoxia consistent with worsening heart failure. The patient’s condition did not improve following RHC and aortic valvuloplasty prompting the patient’s family to withdraw care and admit to hospice, after which he shortly passed.

Conclusion: Despite its rarity, this case demonstrates the importance of recognizing that EuKA remains a risk for those taking an SGLT2i regardless of diabetic status. Of note, we feel the patients use of quetiapine may have contributed to his case given that atypical antipsychotics have been known to increase risk of diabetes and DKA. This is important to note, since the use of atypical antipsychotics has increased in the community. Extra vigilance should be paid to those taking concomitant medications that raise the risk of EuKA, are undergoing surgical intervention, or have comorbid conditions such as diabetes, spinal muscular atrophy, or metabolic derangements.

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