Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 26

26 - Euglycemic DKA triggered by Ketogenic diet- A theoretical concern or actual risk?

Saturday, Apr 27
11:30 AM – 12:00 PM

Objective :

Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are increasingly used to achieve glycemic control in persons with Type 2 Diabetes (T2D). Diabetic ketoacidosis (DKA) occurring in conjunction with SGLT-2 inhibitor therapy have raised concerns, especially among patients taking exogenous insulin. We present an interesting case where a theoretical risk factor actually contributed to DKA in a patient on this treatment.

Methods : n/a

Results : n/a

Discussion :

Case Presentation:

 35 years old male with 12 years history of DM-2 managed on metformin, glipizide and empagliflozin developed severe nausea, vomiting and fatigue. The symptoms were temporally associated with a recent initiation of a ketogenic diet for weight loss. He said he was aware of the risk and was keeping up with oral hydration for the past 2 weeks.  He was admitted to the hospital and was found to have the atypical presentation indicative of euglycemic DKA. He did not have any other comorbid acute illness. Laboratory studies were confirmatory- elevated blood ketones (B-hydroxybutyrate), serum glucose 92 mg/dL, anion gap -19 mEq/L, serum bicarbonate- 10 mEq/L and an arterial pH- 7.16. He had high urine glucose > 1000 mg/dL, and urine ketone >150 mg/dl. Serum lactic acid was normal. Empagliflozin was discontinued at admission. He responded well to IV hydration and insulin treatments. DKA resolved within 48 hours and he was discharged home on the other 2 oral agents and basal insulin. He has continued to do well on subsequent follow-up clinic visits.


SGLT-2 inhibitor- associated DKA occurs occasionally in individuals with diabetes especially those with depleted insulin reserves such as those with latent autoimmune diabetes in adults and Type 1 Diabetes. This most likely is due to non-insulin-dependent glucose clearance, hyperglucagonemia, and decreased ketone clearance. Intercurrent infections, myocardial infarction and excessive alcohol use also increase the risk for DKA. In our patient initiation of a ketogenic diet triggered euglycemic DKA.  

Conclusion :

Patients taking SGLT-2 inhibitors should avoid excess alcohol intake and very-low-carbohydrate/ketogenic diets. These may precipitate DKA even in the absence of other risk factors. This message should be an integral part of ongoing patient education during use of these medications.



Endocrinology Fellow, PGY-5
Texas Tech University health Sciences Center, Permian Basin, Odessa Texas
Odessa, Texas

ABIM Certified 10/2017
Medical Education:
Bachelor of Medicine, Bachelor of Surgery (M.B, B.S.) Khyber Medical College, Peshawar Pakistan. December 2002-November 2008
Post-Graduate Training:
• Endocrinology Fellowship at Texas Tech University Health Sciences Center, Permian Basin, Texas. 6/26/17 – 6/30/19
• Internal Medicine Residency, Grand Rapids Medical Education Partners/Michigan State University Grand Rapids, MI. 06/2013 - 01/2017 • •
Poster Presentation, AACE 25th Annual Scientific & Clinical Congress Orlando Florida 5/2016 Exercising leading to temporary paralysis: A case of familial hypokalemic periodic paralysis. Roger Harty, Syed Azhar Hassan, Nashmia Riaz. GRMEP/MSU Internal Medicine Residency
Atypical presentation of Cushing's disease Syed Azhar Hassan MD, Roger Harty MD, Nashmia Riaz MD, Mohammad Kawji MD GRMEP/MSU IM Residency.
Recent Posters and Abstracts
Siddiqui A, Hasan S, Spellman C, Burks J. An Unusual Presentation of Graves Ophthalmopathy (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Chakrala J, Hasan S, Siddiqui A, Chemitiganti R, Burks J. Parathyroid Crisis in a Young Male (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Hasan S, Siddiqui A, Burks J. A Rare Cause of Graves Disease in HIV Infection (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)

Jahnavi Chakrala

Odessa, Texas

Jahnavi Chakrala, MD,
7/2017- Current- Endocrine Fellowship, TTUHSC, Permian Basin
07/2014- 2/2017- Hospitalist at Presbyterian Hospital, NM
06/2011- 06/2014 - Residency at St. John’s Episcopal Hospital, NY
09/2010-01/2011- Volunteer experience- Methodist University Hospital, Memphis, TN
06/2000-05/2006- Medical school- Narayana Medical College, India
Board Certification- Internal Medicine- 2014
Poster presentations:
Parathyroid Crisis in a Young adult- At AACE, 2017, First author,
Herpes Simplex Pneumonitis in a critically ill patient- At MSSNY, 2013, First author
Fatal Herpes Simplex Virus Hepatitis in an immunocompromised patient- At MSSNY 2013, Second author

Ramachandra Chemitiganti

Endocrinology Faculty
Texas Tech University health Sciences Center, Permian Basin, Odessa Texas, Texas

IM/Endocrinology associate Professor