Euglycemic Diabetic Ketoacidosis with SGLT2 Inhibitor Use in A Patient on The Atkins Diet: A Unique Presentation of A Known Side Effect

ABSTRACT Objective: Euglycemic diabetic ketoacidosis (DKA) is a known potential complication from sodium-glucose cotransporter 2 (SGLT2) inhibitor use. We present a unique case presentation of a 44-year-old, male patient on an SGLT2 inhibitor who developed euglycemic DKA while following a carbohydrate-restricted diet, the Atkins diet. Methods: The patient was on sitagliptin and metformin after a hemoglobin A1c result of 9.3% (78 mmol/mol). Motivated to obtain better glycemic control and weight loss, he started on the Atkins diet, but stayed in the carbohydrate-restricted first phase of the diet. Canagliflozin was added to his regimen 1 month later. Three to four days after starting on the medication, he developed severe abdominal pain. Results: The patient was found to have anion gap metabolic acidosis with an elevated beta-hydroxybutyrate level of 75.50 mg/dL (the reference range is 0.20 to 2.80 mg/dL) and a blood glucose value of 180 mg/dL. Conclusion: The low-carbohydrate diet likely predisposed our patient to a ketogenic metabolic state and the addition of canagliflozin likely precipitated the worsening of his ketosis and subsequent DKA. For patients taking SGLT2 inhibitors, carbohydrate-restricted diet plans may increase the risk of developing euglycemic DKA. Abbreviations: DKA diabetic ketoacidosis SGLT2 sodium-glucose cotransporter 2