title: Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition.
abstract: OBJECTIVE
  Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are the most recently approved antihyperglycemic medications. We sought to describe their association with euglycemic diabetic ketoacidosis (euDKA) in hopes that it will enhance recognition of this potentially life-threatening complication.
  
  
  METHODS
  Cases identified incidentally are described.
  
  
  RESULTS
  We identified 13 episodes of SGLT-2 inhibitor-associated euDKA or ketosis in nine individuals, seven with type 1 diabetes and two with type 2 diabetes, from various practices across the U.S. The absence of significant hyperglycemia in these patients delayed recognition of the emergent nature of the problem by patients and providers.
  
  
  CONCLUSIONS
  SGLT-2 inhibitors seem to be associated with euglycemic DKA and ketosis, perhaps as a consequence of their noninsulin-dependent glucose clearance, hyperglucagonemia, and volume depletion. Patients with type 1 or type 2 diabetes who experience nausea, vomiting, or malaise or develop a metabolic acidosis in the setting of SGLT-2 inhibitor therapy should be promptly evaluated for the presence of urine and/or serum ketones. SGLT-2 inhibitors should only be used with great caution, extensive counseling, and close monitoring in the setting of type 1 diabetes.
authors.affiliation: Keck School of Medicine of the University of Southern California, Los Angeles, CA momofmax@mac.com.
authors.forename: Anne L
authors.initials: AL
authors.lastname: Peters
authors.affiliation: The Ohio State University College of Medicine, Columbus, OH.
authors.forename: Elizabeth O
authors.initials: EO
authors.lastname: Buschur
authors.affiliation: University of North Carolina School of Medicine, Chapel Hill, NC.
authors.forename: John B
authors.initials: JB
authors.lastname: Buse
authors.affiliation: Specialized Endocrine Care Center, Beverly Hills, CA.
authors.forename: Pejman
authors.initials: P
authors.lastname: Cohan
authors.affiliation: University of North Carolina School of Medicine, Chapel Hill, NC.
authors.forename: Jamie C
authors.initials: JC
authors.lastname: Diner
authors.affiliation: University of Washington School of Medicine, Seattle, WA.
authors.forename: Irl B
authors.initials: IB
authors.lastname: Hirsch
mesh_terms: D000328:Adult; D000368:Aged; D001559:Benzhydryl Compounds / Q000008:administration & dosage / Q000009:adverse effects*; D003922:Diabetes Mellitus, Type 1 / Q000188:drug therapy*; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D016883:Diabetic Ketoacidosis / Q000139:chemically induced* / Q000517:prevention & control; D005260:Female; D005960:Glucosides / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D000077203:Sodium-Glucose Transporter 2 Inhibitors
chemical_list: D001559:Benzhydryl Compounds; D005960:Glucosides; D007004:Hypoglycemic Agents; D000077203:Sodium-Glucose Transporter 2 Inhibitors; C570240:empagliflozin