SODIUM-GLUCOSE COTRANSPORTER-2 INHBITORS AND THE RISK OF EUGLYCEMIC DIABETIC KETOACIDOSIS: A NARRATIVE REVIEW

Emil Sergejuk; Wojciech Kotlarski; Klaudia Magdalena Kotlarska; Tomasz Mainka

doi:10.31435/ijitss.2(50).2026.5543

Authors

Emil Sergejuk Mazowiecki Szpital Wojewódzki im. św. Jana Pawła II w Siedlcach Sp. z o.o., ul. Poniatowskiego 26, 08-110 Siedlce, Poland https://orcid.org/0009-0008-5906-4080
Wojciech Kotlarski Mazowiecki Szpital Wojewódzki im. św. Jana Pawła II w Siedlcach Sp. z o.o., ul. Poniatowskiego 26, 08-110 Siedlce, Poland https://orcid.org/0009-0000-7043-3117
Klaudia Magdalena Kotlarska Laboratorium Analiz Medycznych LAMED, ul. Dobra 3, 08-400 Garwolin, Poland https://orcid.org/0009-0005-6089-1161
Tomasz Mainka Mazowiecki Szpital Wojewódzki im. św. Jana Pawła II w Siedlcach Sp. z o.o., ul. Poniatowskiego 26, 08-110 Siedlce, Poland https://orcid.org/0009-0005-7089-4008

DOI:

https://doi.org/10.31435/ijitss.2(50).2026.5543

Keywords:

Sodium-Glucose Cotransporter-2 Inhibitors, Euglycemic Diabetic Ketoacidosis, Metabolic Acidosis, Perioperative Care

Abstract

Background: Euglycemic diabetic ketoacidosis (EuDKA) is a rare but life-threatening metabolic complication associated with the increasing use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). Due to the absence of significant hyperglycemia, clinical diagnosis is frequently delayed, necessitating a high index of suspicion among clinicians.

Methods: This review synthesizes current clinical data, retrospective studies, and international guidelines regarding the pathophysiology, risk factors, and management of SGLT2i-induced euDKA. Specific focus was placed on perioperative protocols and emerging monitoring technologies.

Results: Clinical data indicate that patients with euDKA often present with milder acidosis but a significantly higher incidence of hypoglycemia compared to classic DKA. Effective management requires early initiation of 5–10% glucose infusions alongside insulin therapy to safely inhibit ketogenesis. Risk factors include rigorous low-carbohydrate diets, infection, and major surgery, with some data suggesting that up to 22% of cases initially diagnosed as type 2 diabetes are subsequently reclassified as LADA or type 1 diabetes. Continuous ketone monitoring emerges as a promising tool for early metabolic decompensation detection.

Conclusion: Therapeutic success in euDKA depends on a multidisciplinary approach and rigorous adherence to preventive measures. Key strategies include the discontinuation of SGLT2i 3 to 4 days prior to elective procedures and comprehensive patient education regarding "sick day" rules and hydration.

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