H. Guirguis, S. Beroukhim Afrahimi and C. Pham (2022). The Use of SGLT-2 Inhibitors Coupled With a Strict Low-Carbohydrate Diet: A Set-Up for Inducing Severe Diabetic Ketoacidosis. Clinical medicine insights. Case reports, 15, 11795476221090045. https://doi.org/10.1177/11795476221090045

PubMed 35418794

[Abstract]
A 58-year-old male with a history of hypertension and non-insulin dependent type 2 diabetes mellitus (DM) was brought in by ambulance and admitted to the intensive care unit for weakness, lethargy, and altered mental status and was found to be hypotensive and subsequently diagnosed with severe diabetic ketoacidosis (DKA). A thorough investigation into precipitating factors for his DKA was largely unrevealing; an extensive infectious work- up was negative and the patient's history was otherwise only significant for starting a ketogenic diet 1 month prior while simultaneously being on a sodium-glucose transport protein 2 (SGLT-2) inhibitor, namely empagliflozin. Literature investigation revealed that a strict low carbohydrate diet can rarely lead to DKA in the setting of SLGT-2 inhibitor use.