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Euglycemic diabetic ketoacidosis in the era of SGLT-2 inhibitors
  1. Erica Chow1,
  2. Stephen Clement2,
  3. Rajesh Garg1
  1. 1Division of Endocrinology, Harbor-UCLA Medical Center, Torrance, California, USA
  2. 2Division of Endocrinology, Inova Fairfax Hospital, Falls Church, Virginia, USA
  1. Correspondence to Dr Rajesh Garg; rajesh.garg{at}


Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.

  • ketoacidosis
  • diabetic ketoacidosis
  • drug-related side effects and adverse reactions

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  • Contributors SC and RG conceived the idea. SC prepared an initial sketch and contributed the table. EC performed literature search and wrote the initial draft of the manuscript. RG edited, revised, and prepared a final draft of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.