Empagliflozin and eDKA: A Hidden Danger for Type 2 Diabetics?
"A case report highlights the risk of euglycemic diabetic ketoacidosis (eDKA) in a 68-year-old man treated with empagliflozin, prompting a closer look at SGLT2 inhibitors."
In the ongoing battle against type 2 diabetes, medications like empagliflozin have become essential tools for managing blood sugar levels. Belonging to a class of drugs known as SGLT2 inhibitors, empagliflozin helps the kidneys remove excess glucose from the body, offering a way to improve glycemic control. However, alongside its benefits, a potential danger lurks: euglycemic diabetic ketoacidosis, or eDKA.
eDKA is a serious condition characterized by a buildup of ketones in the blood, leading to acidity. What sets eDKA apart from typical diabetic ketoacidosis is that it can occur even when blood sugar levels are near normal, making it difficult to detect. This atypical presentation can delay diagnosis and treatment, increasing the risk of severe complications.
A recent case report has shed light on the potential risks associated with empagliflozin. The report details the experience of a 68-year-old man with type 2 diabetes who developed eDKA while being treated with empagliflozin. This case underscores the importance of awareness and vigilance when using SGLT2 inhibitors.
Recognizing eDKA with Empagliflozin
Euglycemic diabetic ketoacidosis (euDKA) is uncommon and involves high-anion-gap metabolic acidosis with ketones in the blood or urine despite normal blood glucose levels pmc.ncbi.nlm.nih.gov. A 2023 review describes eDKA as an emerging complication associated with increasing use of SGLT-2 inhibitors and notes that the absence of the usual hyperglycemia can make diagnosis challenging drc.bmj.com. A case report specifically presents empagliflozin-induced eDKA, while another source cautions that empagliflozin’s potential cardioprotective properties do not eliminate its ability to cause the complication.
The Case: A Closer Look at Empagliflozin-Induced eDKA
The case report, originally published in Endocrine Practice, describes a 68-year-old man with a history of type 2 diabetes. He was initially admitted to the hospital for a psoas abscess, a painful collection of pus near the spine. His medical regimen included glipizide and metformin/sitagliptin (Janumet) for four months. His primary care physician added empagliflozin to his dosing regimen.
- Symptoms: The patient's symptoms were initially masked by the primary condition (psoas abscess), making the diagnosis of eDKA more challenging.
- Diagnosis: eDKA was diagnosed based on elevated ketone levels and metabolic acidosis, despite near-normal blood sugar levels.
- Treatment: Empagliflozin was discontinued, and the patient received insulin and intravenous fluids to correct the metabolic imbalance.
- Recovery: The patient's condition gradually improved over several days, with a return to normal bicarbonate levels and closure of the anion gap. Complete metabolic recovery was noted eight days following the last dose of empagliflozin.
eDKA Compared with Typical DKA
The sources describe euglycemic DKA as a rare but serious complication associated with SGLT-2 inhibitor use, often involving multiple contributing factors ncbi.nlm.nih.gov. In contrast with DKA defined by hyperglycemia, euglycemic DKA can present with modestly elevated glucose below 200 mg/dL (11.1 mmol/L) endocrinepractice.org. A second source gives the same threshold—less than 200 mg/dL (11.1 mmol/L)—for euglycemic DKA endocrinepractice.org. This lower glucose level distinguishes eDKA from the typical hyperglycemic presentation described in the sources.
What You Need to Know: Protecting Yourself from eDKA
If you are taking empagliflozin or any other SGLT2 inhibitor, it is essential to be aware of the risks of eDKA and take steps to protect your health. Here are some key recommendations: <ul> <li><b>Know the Symptoms</b>: Be vigilant for symptoms such as nausea, vomiting, abdominal pain, fatigue, and difficulty breathing. These symptoms can be subtle and easily mistaken for other conditions.</li> <li><b>Monitor Ketone Levels</b>: If you experience any of the above symptoms, check your ketone levels using a home ketone test kit. Follow your healthcare provider's instructions on how to interpret the results.</li> <li><b>Stay Hydrated</b>: Dehydration can increase the risk of eDKA. Drink plenty of water throughout the day, especially during periods of illness or increased physical activity.</li> <li><b>Communicate with Your Healthcare Provider</b>: Discuss the risks of eDKA with your doctor or diabetes educator. Make sure they are aware of all your medications and medical conditions.</li> <li><b>Temporary Discontinuation</b>: Certain situations, such as surgery, illness, or reduced food intake, may increase the risk of eDKA. Your healthcare provider may advise you to temporarily stop taking empagliflozin during these times.</li> </ul> By staying informed and taking proactive measures, you can minimize the risk of eDKA and ensure the safe and effective use of empagliflozin in managing your type 2 diabetes.
Awareness and Early Recognition
A 2020 report characterizes SGLT-2 inhibitor-associated euglycemic ketoacidosis as rare but serious and often multifactorial pubmed.ncbi.nlm.nih.gov. It emphasizes that the atypical presentation calls for physician awareness, because early recognition can quickly and safely restore acid-base balance pubmed.ncbi.nlm.nih.gov. A 2021 clinical report explains that DKA typically includes hyperglycemia above 250 mg/dL, ketones, and high-anion-gap metabolic acidosis, while euglycemic DKA may present with normal or mildly elevated glucose diabetesjournals.org.
Treatment and Clinical Course
A 2026 case report describes euglycemic DKA induced by empagliflozin in a patient who was treated after the medication was discontinued. The reported treatment used an insulin infusion and dextrose-containing fluids under a diabetic ketoacidosis protocol. The acidosis resolved and the anion gap closed; the patient’s hematuria also improved with bladder irrigation.
A Patient’s Experience
A case report describes a 57-year-old man who developed euglycemic DKA while receiving empagliflozin for type II diabetes. He presented after a sudden fall and dysarthria, and had also experienced shortness of breath, nausea, and fever for several days. The case illustrates the varied symptoms reported in this individual’s presentation.