Euglycemic diabetic ketoacidosis induced by sodium-glucose cotransporter 2 inhibitor in the setting of prolonged fasting: a case report

Abstract

Background: We describe a case report of a patient with type 2 diabetes on sodium-glucose cotransporter 2 inhibitor and metformin therapy fasting for Ramadan (a holy month observed in the Islamic nation) diagnosed with euglycemic diabetic ketoacidosis. Case presentation: The patient was a 51-year-old Moroccan male with history of type 2 diabetes mellitus on dapagliflozin and metformin. He presented with abdominal pain, vomiting, loss of appetite, and shortness of breath. He observed Ramadan month by fasting an average of 14 hours daily for 30 days. The patient was admitted with severe metabolic acidosis with a high anion gap and positive ketonuria in the setting of serum glucose of 13.5 mmol/L (243 mg/dL). The patient was rehydrated and started on insulin infusion according to the diabetic ketoacidosis protocol following the diagnosis of euglycemic diabetic ketoacidosis. Conclusion: Dapagliflozin is associated with euglycemic diabetic ketoacidosis in the setting of prolonged fasting. Counseling and possible medication adjustment should be added to clinical practice in those planning to decrease caloric intake through dedicated fasting including Ramadan or weight-loss-directed behavioral modifications, especially if taking sodium-glucose cotransporter 2 inhibitors.