A Case of Euglycemic Diabetic Ketoacidosis Triggered by a Ketogenic Diet in a Patient With Type 2 Diabetes Using a Sodium–Glucose Cotransporter 2 Inhibitor

Sodium–glucose cotransporter 2 (SGLT2) inhibitors are one of the newest classes of antihyperglycemic medications now available for the treatment of type 2 diabetes (1). Clinical guidelines recommend this type of medication as one of various possible approaches for pharmacological therapy after failure of or intolerance to metformin (1).

SGLT2 inhibitors are the first class of medications that act on the kidneys to optimize glycemic control; they prevent the reabsorption of glucose in the proximal renal tubules by targeting the action of the protein SGLT2 (2). As glucose is excreted through the urine, plasma glucose levels fall, leading to an improvement in glycemia (1).

The most common adverse side effects attributed to SGLT2 inhibitors are genital and urinary infections. Because of osmotic diuresis induced by the glucosuria resulting from SGLT2 inhibition, volume depletion is also a possibility (3). Recently, episodes of diabetic ketoacidosis (DKA) have been identified as a rare side effect (2).

As a consequence of the glucosuria induced by SGLT2 inhibition, the majority of reported DKA episodes have been associated with a mild to moderate increased glycemia (4).