Endocrine Abstracts

Introduction: Euglycaemic diabetic ketoacidosis (euglycaemic DKA) is an uncommon but serious metabolic disorder characterised by ketoacidosis with normal or mildly raised blood glucose levels. While classically associated with the concomitant use of sodium-glucose cotransporter-2 (SGLT2) inhibitors, the concomitant use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), such as semaglutide has also been implicated.

Case study: A 37-year-old woman presented with a one-day history of nausea, vomiting, and malaise. Medical history included type 2 diabetes mellitus and overweight. Medications included metformin and semaglutide. She was previously taking canagliflozin, which had been stopped three months prior, and semaglutide was started three weeks prior to presentation. She was a non-smoker and did not drink alcohol. Examination was unremarkable. She had a body mass index of 39 kg/m2.

Investigation and management: Investigations demonstrated metabolic acidosis with ketosis and mild hyperglycaemia (glucose value:10.7 mmol/l) consistent with euglycaemic DKA. She also had mild leukocytosis with an elevated c-reactive protein level of 8 mg/l. Her renal function was normal. A test for COVID-19 infection was incidentally positive. Her c-peptide and pancreatic autoimmune antibodies were normal. She was given a diagnosis of euglycaemic DKA precipitated by gastroenteritis. She was treated according to the DKA management guidelines and made a rapid recovery. She was discharged on metformin, gliclazide and once a day long-acting insulin (glargine).

Discussion: We have presented a case of euglycemic diabetic ketoacidosis in a patient taking Semaglutide. The interaction between intercurrent illness, reduced intake, and relative insulin deficiency probably precipitated euglycaemic DKA in this patient. Prior SGLT2 inhibitor exposure may have further increased risk, as these agents can predispose to DKA even after discontinuation due to residual metabolic effects. Clinicians should remain alert for euglycaemic DKA occurring in patients taking semaglutide, particularly with recent SGLT2 use.