This patient has acute anion gap metabolic acidosis associated with abdominal pain, nausea, and vomiting. In light of the positive urine ketone screen, this most likely represents euglycemic diabetic ketoacidosis (euDKA), a recognized complication of sodium-glucose cotransporter-2 (SGLT2) inhibitor (eg, canagliflozin) therapy.
SGLT2 inhibitors lower blood glucose by reducing reabsorption of glucose in the kidney, which leads to a low insulin-to-glucagon ratio because high blood glucose levels are the primary stimulus for insulin release. euDKA in patients taking SGLT2 inhibitors can be triggered by prolonged fasting, major illness, intense exercise, excessive alcohol intake, or an abrupt reduction in concurrent insulin dose. These conditions further lower the insulin-to-glucagon ratio and exacerbate relative insulin deficiency to the point of stimulating ketogenesis.
In contrast to typical DKA, which is associated with very high glucose levels, blood glucose in SGLT2-associated euDKA is usually <250 mg/dL due to the increased excretion of glucose in the urine. Management includes aggressive hydration, discontinuation of the drug, and control of blood glucose with insulin.
