A Case of Euglycemic Diabetic Ketoacidosis Triggered by a Ketogenic Diet in a Patient With Type 2 Diabetes Using a Sodium–Glucose Cotransporter 2 Inhibitor

Sodium–glucose cotransporter 2 (SGLT2) inhibitors are one of the newest classes of antihyperglycemic medications now available for the treatment of type 2 diabetes (1). Clinical guidelines recommend this type of medication as one of various possible approaches for pharmacological therapy after failure of or intolerance to metformin (1).SGLT2 inhibitors are the first class of medications that act on the kidneys to optimize glycemic control; they prevent the reabsorption of glucose in the proximal renal tubules by targeting the action of the protein SGLT2 (2). As glucose is excreted through the urine, plasma glucose levels fall, leading to an improvement in glycemia (1).The most common adverse side effects attributed to SGLT2 inhibitors are genital and urinary infections. Because of osmotic diuresis induced by the glucosuria resulting from SGLT2 inhibition, volume depletion is also a possibility (3). Recently, episodes of diabetic ketoacidosis (DKA) have been identified as a rare side effect (2).As a consequence of the glucosuria induced by SGLT2 inhibition, the majority of reported DKA episodes have been associated with a mild to moderate increased glycemia (4).R.F., a 44-year-old man with a history of type 2 diabetes, presented to the hospital emergency department with complaints of malaise, fatigue, heartburn, and decreased exercise capacity. He had been taking the dipeptidyl peptidase 4 inhibitor sitagliptin 100 mg, the SGLT2 inhibitor empagliflozin 25 mg, and metformin 1,000 mg twice daily for the past 2 years. He said his symptoms started 4 days earlier. The only change he could identify in his lifestyle was that he had switched to a ketogenic diet and was restricting carbohydrates, which he had been doing for 7 days before coming to the hospital.R.F.’s heart rate was 120 bpm, his blood pressure was 120/80 mmHg, and his temperature was 97.8°F. On physical …