Euglycemic Ketoacidosis in a Patient without Diabetes Taking Sodium-Glucose Cotransporter 2 Inhibitors for Heart Failure

Abstract

Patient: Female, 83-year-old Final Diagnosis: Metabolic acidosis • sodium-glucose cotransporter 2 • heart failure Symptoms: Anorexia • nausea and vomiting Clinical Procedure: — Specialty: Cardiology • Endocrinology and Metabolic Objective: Rare coexistence of disease or pathology Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are used to improve the prognosis of patients with diabetes, heart failure, or chronic kidney disease. The use of SGLT2 inhibitors in patients without diabetes is expected to increase. Diabetic ketoacidosis is a severe complication of SGLT2 inhibitors in patients with diabetes. People without diabetes are thought to be less likely to develop ketoacidosis, and reports of SGLT2 inhibitorinduced ketoacidosis are uncommon in people without diabetes. Case Report: Herein, we describe a case of ketoacidosis in an 83-year-old Japanese woman without diabetes who was administered SGLT2 inhibitors for heart failure (ejection fraction: approximately 30%). Two weeks prior to admission, she had suffered a vertebral fracture and rib fracture due to a fall, which was followed by anorexia, but she continued to take SGLT2 inhibitors. On admission, blood test results revealed a blood glucose level – of 124 mg/dL, hemoglobin A1C level of 5.9%, pH of 7.329, HCO3- concentration of 14.3 mmol/L, and a b-hydroxybutyrate concentration of 5150 μmol/L, leading to a diagnosis of euglycemic ketoacidosis. The patient’s C-peptide level was consistent with the blood glucose levels on admission, indicating that she had adequate insulin secretion. The patient was treated only with glucose administration without insulin and was discharged after discontinuation of the SGLT2 inhibitor. Conclusions: This case illustrates that patients with or without diabetes may develop SGLT2 inhibitor-related ketoacidosis after several days of inadequate food intake; therefore, patients should be informed of this risk.