Euglycemic diabetic ketoacidosis

Learning objectives

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

Starvation resulting in ketosis while maintaining normoglycemia
- Anorexia
- Gastroparesis
- Fasting
- Use of a ketogenic diet
- Alcohol use
- Persistent vomiting
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