POTD: Euglycemic DKA

Today’s POTD comes from Dr. Buckingham.  Her clinical question: Can a patient present as a first time diabetic with euglycemic DKA? Hmmm... Let’s break question down.  

How do you diagnose diabetes in a patient?

  • Symptomatic hyperglycemia with classic symptoms of thirst, polyuria, weight loss with a random BGM≥200mg/dL
  • Fasting plasma glucose ≥126 mg/dL
  • Oral glucose tolerance test with two hour plasma glucose ≥200 mg/dL
  • HbA1C values ≥6.5%

 

What is euglycemic DKA?

Just as the name states, euglycemic DKA is diabetic ketoacidosis without the hyperglycemia.  Patients will have the serum/urine ketones and anion gap metabolic acidosis of DKA while glucose levels are normal/mildly elevated (<200mg/dL).  Patients that present with euglycemic DKA are usually those with poor carbohydrate intake, adequate hydration, use of insulin, alcohol intake, or use of sodium-glucose co-transporter 2 (SGLT2) inhibitors [Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)].  Euglycemic DKA occurs more often in type 1 but can also occur in type 2 diabetes, and the most common symptom is vomiting.

**Check labs for patients with concerning story of DM, poor carbohydrate intake and/or taking SGLT2 inhibitor, c/o nausea/vomiting/fatigue/SOB**

 

So can someone present with no prior hx of diabetes and have euglycemic DKA?

Maybe, if they have been having poor carbohydrate intake but tolerating fluids.  However, also consider a broader differential diagnosis such as starvation ketoacidosis, alcoholic ketoacidosis, lactic acidosis, and drug toxicity.

 

Want to read more?

http://care.diabetesjournals.org/content/38/9/1638

https://emergencymedicinecases.com/euglycemic-dka/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4488998/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592704/

http://rebelem.com/euglycemic-dka-not-myth/

https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-diabetes-mellitus-in-adults

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