CC. Chen, TY. Feng, SC. Wang, TH. Chen, SJ. Chou and HC. Jan (2025). SGLT-2 inhibitor induced Euglycemic diabetes ketoacidosis in post laparoscopic distal pancreatectomy: A case report. International journal of surgery case reports, 128, 111006. https://doi.org/10.1016/j.ijscr.2025.111006

PubMed 39923447

[Abstract]
INTRODUCTION AND IMPORTANCE: Euglycemic diabetic ketoacidosis is a rare but serious adverse effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors. They are a newer class of oral hypoglycemic drugs commonly prescribed for managing patients with diabetes mellitus.

CASE PRESENTATION: We present a case of a woman in her 60s with type 2 diabetes mellitus hospitalized for operation of pancreatic body tumor who developed dapagliflozin-associated euglycemic diabetic ketoacidosis despite having stopped the medication before operation. She underwent laparoscopic distal pancreatectomy and occurred euglycemic diabetic ketoacidosis during post-operative period.

CLINICAL DISCUSSION: Surgical stress, acute postoperative illness, and decreased carbohydrate intake are postulated to be contributing factors to the development of ketosis in this patient, while near-normal glucose levels initially suggested non-diabetic ketoacidosis physiology and led to delayed diagnosis and treatment. Patients with type 2 diabetes mellitus may develop diabetic ketoacidosis during states of relative insulinopenia, most frequently from inadequate medication or intercurrent illness. During periods of carbohydrate deficiency, volume depletion, and up-regulation of counter-regulatory stress hormones, SGLT2 inhibitor therapy can promote lipolysis and ketogenesis while maintaining euglycemia.

CONCLUSION: Clinical considerations to ensure safe SGLT2 inhibitor therapy include appropriate holding parameters, timely diagnosis of euglycemic diabetic ketoacidosis, and recognition that the pharmacologic effects of SGLT2 inhibitor treatment may persist beyond several half-lives of elimination.