Stereotypical diagnostic bias for alcohol-induced ketoacidosis could lead to death: Normal blood sugar levels in SGLT2 blocker-induced severe diabetic ketoacidosis.

BACKGROUND: Ketoacidosis, a life-threatening disease, can be caused by diabetes, alcohol consumption, and severe malnutrition, which are not uncommon in psychiatry. Diabetic and alcoholic ketoacidosis (AKA) are particularly frequent, and differentiating between these two is essential in terms of the substantially different treatment interventions. In recent years, the advent of sodium-glucose co-transporter 2 (SGLT2) inhibitors has made this distinction more difficult, mainly due to the increase in euglycemic diabetic ketoacidosis (euDKA)-ketoacidosis in normal or near-normal blood sugar levels-in the presence of SGLT2 inhibitors.

CASE PRESENTATION: We describe a 52-year-old man's case of severe euDKA caused by an SGLT2 inhibitor with alcohol use disorder. We initially suspected mainly AKA due to his mild disturbance of consciousness, habitual high intake of alcohol, and almost normal blood glucose level (142 mg/dL). We administered supplemental fluids and vitamin B complex instead of insulin, which is needed for euDKA, but his disorientation and metabolic acidosis worsened. Upon recognizing his inadequate response to fluid replacement and considering his history of SGLT2 inhibitor use, we identified euDKA as the primary pathology. Implementing continuous insulin therapy and tight glycemic control resulted in a rapid improvement in the patient's condition.

CONCLUSION: Even with normal or near-normal blood sugar levels in a patient with suspected AKA, missing the possibility of euDKA can be fatal. Therefore, psychiatrists should remain vigilant for euDKA, especially in patients using SGLT2 inhibitors, by conducting frequent blood gas examinations.