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Metabolic Acidosis and its Predisposing Factor: Euglycemic Ketoacidosis Caused by Empagliflozin and Low-Carbohydrate Ketogenic Diet in Type 2 Diabetes Mellitus. Case Report

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Abstract

Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are medications used in type 2 diabetes mellitus (T2DM) that control high blood sugar levels and promote normoglycemia by preventing glucose reabsorption and facilitating glucosuria. Three SGLT2i (canagliflozin, dapagliflozin, and empagliflozin) are approved in the United States. Euglycemic ketoacidosis or ketoacidosis with a lower than expected hyperglycemia is a rare adverse event associated with SGLT2i. Low-carbohydrate ketogenic diet (LCKD) may lower the threshold for the development of SGLT2i-induced ketoacidosis in T2DM. We report a rare case of diabetic ketoacidosis in a type 2 diabetic patient with a blood glucose level of 159 mg/dl in the presence of empagliflozin and LCKD. He had recently started eating a LCKD. He presented with the nonspecific complaints of fatigue, headache, nausea, abdominal pain, and chest discomfort. He had run out of his anti-diabetic medications and started retaking them a week ago. Labs showed metabolic acidosis with ketonuria and glucosuria. His presentation was attributed to the reintroduction of empagliflozin in the presence of a LCKD. SGLT2i put patients at risk of euglycemic ketoacidosis in T2DM due to glucosuria, euglycemia, and suppressed insulin release. Lifestyle changes, such as LCKD, may lower the threshold further due to excessive lipolysis, beta-oxidation, and hepatic ketogenesis. Practitioners should educate patients about this adverse effect. Patients should consult with their physicians before incorporating a LCKD in their lifestyle if they are using SGLT2i.

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AK wrote the case. KM and RR managed the patient and discussed the case with AK. MK, MKK, and RM did the literature review and wrote the introduction and discussion sections. AW did the literature review and edited the entire article for the submission.

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Correspondence to Ahsan Wahab.

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Khan, A., Mushtaq, K., Khakwani, M. et al. Metabolic Acidosis and its Predisposing Factor: Euglycemic Ketoacidosis Caused by Empagliflozin and Low-Carbohydrate Ketogenic Diet in Type 2 Diabetes Mellitus. Case Report. SN Compr. Clin. Med. 2, 1243–1247 (2020). https://doi.org/10.1007/s42399-020-00367-0

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