Risk of Euglycemic Diabetic Ketoacidosis Due to Low-carbohydrate Diet While Taking Empagliflozin: a Case Report

Empagliflozin reduces blood glucose levels independently of insulin secretion by reducing glucose reabsorption in the proximal renal tubules through inhibition of sodium-glucose cotransporter 2 (SGLT2). Because SGLT2 inhibitors have a different mechanism of action to conventional antidiabetic drugs, recommendations have been issued about the management of specific side effect such as ketoacidosis, urinary tract infection, and genital infection. There have been some reports of SGLT2 inhibitor-associated euglycemic diabetic ketoacidosis (euDKA), but there have been few reports about euDKA in patients with type 2 diabetes using SGLT2 inhibitors while on a low-carbohydrate diet. Here we report a patient who developed euDKA after starting a very low-carbohydrate diet while taking empagliflozin. A 51-year-old man was hospitalized with nausea and vomiting, and investigations revealed metabolic acidosis. euDKA was diagnosed from the information about medications in his drug notebook and a history of eating a low-carbohydrate diet (1900 kcal, consisting of 5.7% carbohydrate, 21.1 % protein, 47.3% fat and 25.9% alcohol) for 4 d. The patient improved after infusion of acetated Ringer's solution with 5% glucose and administration of regular insulin. It is necessary for physicians and pharmacists to thoroughly inform patients about the side effects of SGLT2 inhibitors such as ketoacidosis, urinary tract infection, and genital infection. Patients should also be advised about the higher risk of euDKA associated with a low-carbohydrate diet while taking SGLT2 inhibitors.