title: Euglycemic Diabetic Ketoacidosis with Elevated Acetone in a Patient Taking a Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor.
abstract: BACKGROUND
  Sodium-glucose cotransporter-2 (SGLT2) inhibitor medications are a class of antihyperglycemic agents that increase urinary glucose excretion by interfering with the reabsorption of glucose in the proximal renal tubules. In May of 2015, the U.S. Food and Drug Administration released a warning concerning a potential increased risk of ketoacidosis and ketosis in patients taking these medications.
  
  
  METHODS
  We present a case of a 57-year-old woman with type 2 diabetes mellitus taking a combination of canagliflozin and metformin who presented with progressive altered mental status over the previous 2 days. Her work-up demonstrated a metabolic acidosis with an anion gap of 38 and a venous serum pH of 7.08. The serum glucose was 168 mg/dL. The urinalysis showed glucose > 500 mg/dL and ketones of 80 mg/dL. Further evaluation demonstrated an elevated serum osmolality of 319 mOsm/kg and an acetone concentration of 93 mg/dL. She was treated with intravenous insulin and fluids, and the metabolic abnormalities and her altered mental status resolved within 36 h. This was the first episode of diabetic ketoacidosis (DKA) for this patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diabetic patients on SGLT2 inhibitor medications are at risk for ketoacidosis. Due to the renal glucose-wasting properties of these drugs, they may present with ketoacidosis with only mild elevations in serum glucose, potentially complicating the diagnosis. Acetone is one of the three main ketone bodies formed during DKA and it may be present at considerable concentrations, contributing to the serum osmolality.
authors.affiliation: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Tory J
authors.initials: TJ
authors.lastname: Andrews
authors.affiliation: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi; Mississippi Poison Control Center, Jackson, Mississippi.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Cox
authors.affiliation: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi; Mississippi Poison Control Center, Jackson, Mississippi.
authors.forename: Christina
authors.initials: C
authors.lastname: Parker
authors.affiliation: Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: James
authors.initials: J
authors.lastname: Kolb
mesh_terms: D000096:Acetone / Q000032:analysis* / Q000097:blood; D000959:Antihypertensive Agents / Q000009:adverse effects / Q000627:therapeutic use; D001786:Blood Glucose / Q000032:analysis; D000068896:Canagliflozin / Q000009:adverse effects / Q000627:therapeutic use; D048909:Diabetes Complications; D016883:Diabetic Ketoacidosis / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007328:Insulin / Q000494:pharmacology / Q000627:therapeutic use; D008687:Metformin / Q000494:pharmacology / Q000627:therapeutic use; D008875:Middle Aged; D051297:Sodium-Glucose Transporter 2 / Q000819:agonists* / Q000627:therapeutic use
chemical_list: D000959:Antihypertensive Agents; D001786:Blood Glucose; D007328:Insulin; D051297:Sodium-Glucose Transporter 2; D000068896:Canagliflozin; D000096:Acetone; D008687:Metformin
keywords: SGLT2; acetone; canagliflozin; euglycemic diabetic ketoacidosis; sodium-glucose cotransporter-2 inhibitors