EUGLYCEMIC DIABETIC KETOACIDOSIS ASSOCIATED WITH SGLT2 INHIBITORS IN AN ELDERLY PATIENT WITH CARDIOGENIC SHOCK

Abstract

Sodium–glucose cotransporter-2 inhibitors (SGLT2i) have emerged as a fundamental component of contemporary heart failure therapy, demonstrating reductions in cardiovascular mortality, hospitalizations, symptom burden, and preservation of renal function, irrespective of the presence of diabetes mellitus. Despite these substantial benefits, SGLT2 inhibitors are associated with certain adverse effects, among which euglycemic diabetic ketoacidosis (euDKA) represents a rare but potentially life-threatening and frequently underrecognized complication. We present the case of a 63-year-old male with a medical history of hypertension and type 2 diabetes mellitus who was admitted with acute myocardial infarction. The patient underwent emergency coronary intervention eight hours after symptom onset and was subsequently transferred to a cardiovascular center for continued inpatient management. During hospitalization, he developed high anion gap metabolic acidosis with normal blood glucose levels following the initiation of an SGLT2 inhibitor as part of heart failure therapy. This case highlights a noteworthy adverse reaction related to SGLT2 inhibitor use, particularly in the context of cardiogenic shock or unstable hemodynamics. In older adults, the clinical presentation of ketoacidosis may be nonspecific and atypical, contributing to delays in recognition and diagnosis. Ketoacidosis constitutes a severe metabolic derangement which, when superimposed on acute cardiovascular disease, may exacerbate circulatory failure and increase mortality risk. Accordingly, initiation of heart failure pharmacotherapy—especially SGLT2 inhibitors—should be carefully individualized with consideration of hemodynamic status and timing, accompanied by close monitoring for ketoacidosis in high-risk populations, including elderly patients and those with diabetes, malnutrition, or prolonged fasting. Such a cautious approach facilitates optimization of the therapeutic benefits of SGLT2 inhibitors while mitigating the risk of serious metabolic complications.

Keywords: elderly patients; heart failure; cardiogenic shock; euglycemic diabetic ketoacidosis