Haridas Keerthana, Iafe Timothy, McConnell Megan
Division of Endocrinology, Diabetes and Metabolism, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California.
Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California.
AACE Endocrinol Diabetes. 2025 Apr 10;12(1):11-14. doi: 10.1016/j.aed.2025.03.002. eCollection 2025 May-Jun.
BACKGROUND/OBJECTIVE: Euglycemic diabetic ketoacidosis (eDKA) is a well-recognized complication with sodium linked cotransport of glucose-2 inhibitor (SGLT2i) use. Recurrent eDKA is an infrequently described entity. We describe a patient with recurrent eDKA precipitated by diabetic myonecrosis.
A 48-year-old male with Diabetes Mellitus treated with empagliflozin and insulin, presented with left thigh pain and anorexia. Physical examination was notable for BMI 16 kg/m and left thigh tender induration. Laboratory evaluation revealed pH 7.1, bicarbonate 10 mmol/L, anion gap 32 mmol/L, glucose 168 mg/dl, erythrocyte sedimentation rate 67 mm/hr, Creatine Kinase 31 U/L, glucosuria (4+), ketonuria (4+), HbA1c 11.3%, C-peptide <0.5 ng/ml and glutamic acid decarboxylase antibody titer 64.3 IU/ml. He was diagnosed with eDKA due to SGLT2i use. Empagliflozin was discontinued. MRI of the left thigh revealed diabetic myonecrosis. He was treated with insulin infusion leading to eDKA resolution on hospital day 3. On hospital day 5, bicarbonate was 15 mmol/L, anion gap 18 mmol/L, beta-hydroxybutyrate 49.6 mg/dl, glucose 185 mg/dl, glucosuria (4+) and ketonuria (4+). Recurrent eDKA was diagnosed. Insulin infusion was re-started, causing resolution. The patient was treated with cefazolin and underwent surgical debridement of necrotic muscle.
The risk of eDKA with SGLT2i use is increased in patients with T1DM with decreased oral intake, surgery or trauma. Although the half-life of empagliflozin is 12 to 14 hours, persistent euglycemic DKA for 7 to 12 days from the last dose has been reported. Persistent glucosuria and ketonuria in this patient with serum glucose below the renal threshold confirmed recurrent eDKA.
eDKA may recur until 2 weeks from last dose of SGLT2i under certain conditions.
背景/目的：正常血糖性糖尿病酮症酸中毒（eDKA）是使用钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）时一种公认的并发症。复发性eDKA是一种较少被描述的情况。我们报告一例由糖尿病性肌坏死引发复发性eDKA的患者。
一名48岁男性糖尿病患者，正在使用恩格列净和胰岛素治疗，出现左大腿疼痛和厌食症状。体格检查显示体重指数（BMI）为16kg/m，左大腿压痛性硬结。实验室检查结果为：pH值7.1，碳酸氢盐10mmol/L，阴离子间隙32mmol/L，血糖168mg/dl，红细胞沉降率67mm/hr，肌酸激酶31U/L，尿糖（4+），尿酮体（4+），糖化血红蛋白（HbA1c）11.3%，C肽<0.5ng/ml，谷氨酸脱羧酶抗体滴度64.3IU/ml。他因使用SGLT2i被诊断为eDKA。停用恩格列净。左大腿磁共振成像（MRI）显示糖尿病性肌坏死。给予胰岛素输注治疗，患者在住院第3天eDKA得到缓解。住院第5天，碳酸氢盐为15mmol/L，阴离子间隙18mmol/L，β-羟丁酸49.6mg/dl，血糖185mg/dl，尿糖（4+），尿酮体（4+）。诊断为复发性eDKA。重新开始胰岛素输注，病情缓解。患者接受头孢唑林治疗，并对坏死肌肉进行手术清创。
1型糖尿病患者在口服摄入量减少、手术或创伤时，使用SGLT2i发生eDKA的风险增加。尽管恩格列净的半衰期为12至14小时，但有报告称在最后一剂后持续7至12天出现持续性正常血糖性DKA。该患者血清葡萄糖低于肾阈值时仍持续存在尿糖和尿酮体，证实为复发性eDKA。
在某些情况下，eDKA可能在最后一剂SGLT2i后2周内复发。
