Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 26 , ISSUE 1 ( January, 2022 ) > List of Articles


“The Bitter Truth of Sugar”—Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series

Edwin Pathrose, Nikhil M Bhagwat, David Chandy

Keywords : Euglycemia, Gliflozins, Glycosuria, High anion gap metabolic acidosis, Intensive care unit, Oral hypoglycemic agents, Sodium-glucose cotransporter-2 inhibitors

Citation Information : Pathrose E, Bhagwat NM, Chandy D. “The Bitter Truth of Sugar”—Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series. Indian J Crit Care Med 2022; 26 (1):123-126.

DOI: 10.5005/jp-journals-10071-24076

License: CC BY-NC 4.0

Published Online: 17-01-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Diabetic ketoacidosis (DKA) is an acute and major complication of diabetes mellitus (DM), both type I and type II. Biochemically, DKA consists of a triad of blood sugar levels greater than 250 mg/dL, ketonemia of greater than 3 mmol/L and/or significant ketonuria, and a blood pH less than 7.3 with an increased anion gap. Currently, the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are widely used in management of type II diabetes. There have been several reports of an association between euglycemic diabetic ketoacidosis (EuDKA) and SGLT-2i agents. We present three different patients who were on SGLT-2i therapy who developed recurrent EuDKA postprocedure or sepsis. We believe that prolonged treatment (5–6 days) with intravenous (IV) insulin with glucose until resolution of glycosuria can be considered as an inexpensive marker of resolution of EuDKA. Moreover, the recommended duration for discontinuation of these drugs prior to elective procedures should be longer than 3 days.

  1. FDA Drug Safety Communication: FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. Available from: [Last accessed on April 15, 2021].
  2. Gauthier PM, Szerlip HM. Metabolic acidosis in the intensive care unit. Crit Care Clin 2002;18(2):289–308. DOI: 10.1016/s0749-0704(01)00012-4.
  3. Barski L, Eshkoli T, Brandstaetter E, Jotkowitz A. Euglycemic diabetic ketoacidosis. Eur J Intern Med 2019;63:9–14. DOI: 10.1016/j.ejim.2019.03.014.
  4. Diaz-Ramos A, Eilbert W, Marquez D. Euglycemic diabetic ketoacidosis associated with sodium-glucose cotransporter-2 inhibitor use: a case report and review of the literature. Int J Emerg Med 2019;12(1):1–4. DOI: 10.1186/s12245-019-0240-0.
  5. Ferrannini E, Baldi S, Frascerra S, Astiarraga B, Barsotti E, Clerico A, et al. Renal handling of ketones in response to sodium–glucose cotransporter 2 inhibition in patients with type 2 diabetes. Diabetes Care 2017;40(6):771–776. DOI: 10.2337/dc16-2724.
  6. Taylor SI, Blau JE, Rother KI. SGLT2 inhibitors may predispose to ketoacidosis. J Clin Endocrinol Metab 2015;100(8):2849–2852. DOI: 10.1210/jc.2015-1884.
  7. Westcott GP, Segal AR, Mitri J, Brown FM. Prolonged glycosuria and relapse of diabetic ketoacidosis related to SGLT2-inhibitor therapy. Endocrinol Diabetes Metab 2020;3(2):e00117. DOI: 10.1002/edm2.
  8. Bonora BM, Avogaro A, Fadini GP. Extraglycemic effects of SGLT2 inhibitors: a review of the evidence. Diabetes Metab Syndr Obes 2020;13:161. DOI: 10.2147/DMSO.S233538.
  9. FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections – FDA Drug Safety Communication. March 19, 2020. Available from:
  10. Zala A, Maple-Brown LJ, Shaw JE, Hare MJ. Current evidence and practical guidance for the use of sodium-glucose Cotransporter-2 inhibitors in type 2 diabetes. Aust J Gen Pract 2021;50(4):225–230. DOI: 10.31128/AJGP-05-20-5432.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.