SAT-638 - Delayed Euglycemic Diabetic Ketoacidosis Six Days After Sodium–Glucose Cotransporter-2 Inhibitor Discontinuation Following Endoscopic Retrograde Cholangiopancreatography

Background: Euglycemic diabetic ketoacidosis (eDKA) is a recognized complication of sodium–glucose cotransporter-2 (SGLT2) inhibitors, characterized by high anion gap metabolic acidosis with elevated ketones despite near-normal glucose levels. Current perioperative guidelines recommend withholding SGLT2 inhibitors for at least three days prior to surgery; however, delayed presentations beyond this window have been increasingly reported.

Case Presentation: We describe a 68-year-old woman with type 2 diabetes mellitus treated with empagliflozin who developed eDKA six days after discontinuation of the medication. She was admitted for evaluation of obstructive jaundice and underwent endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, ultimately diagnosed with pancreatic adenocarcinoma. Despite holding empagliflozin, she developed high anion gap metabolic acidosis with low bicarbonate, elevated beta-hydroxybutyrate, and acidemia, consistent with euglycemic diabetic ketoacidosis, with rapid resolution following intravenous insulin therapy.

Discussion: This case highlights the multifactorial pathogenesis of eDKA, including relative insulin deficiency, procedural stress, reduced oral intake, and possible impaired endogenous insulin secretion in the setting of pancreatic disease. Importantly, it underscores the potential for prolonged pharmacodynamic effects of SGLT2 inhibitors, with delayed onset of eDKA beyond the commonly recommended preprocedural discontinuation period. Unlike prior reports largely associated with major surgery or critical illness, this case occurred following a minimally invasive procedure.

Conclusion: Clinicians should maintain a high index of suspicion for eDKA even several days after discontinuation of SGLT2 inhibitors. The risk may extend beyond major surgical settings to include less invasive procedures, suggesting that current withholding recommendations may be insufficient for certain high-risk patients.

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