Euglycemic diabetic ketoacidosis - NYSORA

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Euglycemic diabetic ketoacidosis

Euglycemic diabetic ketoacidosis

Learning objectives

  • Definition of euglycemic diabetic ketoacidosis (EDKA)
  • Management of EDKA

Definition and mechanisms

  • Diabetic ketoacidosis (DKA) is defined as metabolic acidosis with hyperglycemia and increased ketone bodies in the blood and urine, with hyperglycemia the hallmark for the diagnosis of DKA
  • However, in a subset of patients, are the serum glucose levels within the normal limits, this is defined as euglycemic diabetic ketoacidosis (EDKA)
  • This rare condition is a diagnostic challenge as euglycemia masquerades the underlying diabetic ketoacidosis
  • Occurs in both type 1 and type 2 diabetes mellitus and can be life-threatening
  • EDKA is secondary to a carbohydrate deficit resulting in generalized decreased serum insulin and excess hormones such as glucagon, epinephrine, and cortisol
  • The increased glucagon/insulin ratio leads to increased lipolysis, increased free fatty acids, and ketoacidosis
  • The resulting anion gap metabolic acidosis triggers respiratory compensation and sensation of dyspnea, as well as nausea, anorexia, and vomiting
  • The resulting volume depletion further exacerbates elevations in glucagon, cortisol, and epinephrine, worsening lipolysis and ketogenesis
  • Additionally, decreased hepatic gluconeogenesis or increased glucosuria contribute to EDKA

Signs and symptoms

  • Metabolic acidosis (pH < 7.3, serum bicarbonate < 18 mEq/L)
  • Ketonomia or kenonuria
  • Normal blood glucose levels < 250 mg/dL
  • Malaise
  • Dyspnea
  • Nausea
  • Vomiting
  • Confusion
  • Excessive thirst/urination
  • Kussmaul respiration (deep, rapid)

Etiology

  • Starvation resulting in ketosis while maintaining normoglycemia
  • Pregnancy
  • Pancreatitis
  • Glycogen storage disorders
  • Surgery
  • Infection
  • Cocaine toxicity
  • Cirrhosis
  • Insulin pump use
  • Dehydration
  • Sodium-glucose cotransporter 2 (SGLT2) inhibitors: 
    • SGLT2 inhibition in the proximal renal tubules promotes glycosuria
    • Resulting in diminished insulin production and elevated plasma glucagon concentrations

Complications

Diagnosis

  • Blood or urine ketone testing
  • Laboratory evaluation:
    • Electrolytes
    • Glucose
    • Calcium
    • Magnesium
    • Creatinine
    • BUN
    • Serum and urine ketones 
    • Beta-hydroxybutyric acid
    • Arterial or venous blood gas analysis
    • Lactic acid
    • Chest X-ray
    • ECG
    • Serum osmolality
    • Alcohol

Management

Euglycemic diabetic ketoacidosis, fluid resuscitation, anion gap, acidosis, insulin, dextrose, potassium, SGLT2 inhibitors, dexamethasone, euvolemia

Suggested reading

  • Nasa P, Chaudhary S, Shrivastava PK, Singh A. Euglycemic diabetic ketoacidosis: A missed diagnosis. World J Diabetes. 2021;12(5):514-523.
  • Thiruvenkatarajan, V., Meyer, E.J., Nanjappa, N., Van Wijk, R.M., Jesudason, D., 2019. Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review. British Journal of Anaesthesia 123, 27–36.
  • Rawla, P., Vellipuram, A.R., Bandaru, S.S., Pradeep Raj, J., 2017. Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma. Endocrinology, Diabetes & Metabolism Case Reports 2017.
  • Modi A, Agrawal A, Morgan F. Euglycemic Diabetic Ketoacidosis: A Review. Curr Diabetes Rev. 2017;13(3):315-321.

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