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Cited by 139Diabetes Management and ResearchRenal function and acid-base balanceDiabetes Treatment and Management

Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma

Open access
Rawla, Prashanth, Vellipuram, Anantha R, Bandaru, Sathyajit S, Pradeep Raj, Jeffrey·2017·Endocrinology, Diabetes & Metabolism Case Reports
DOI 10.1530/edm-17-0081PMC PMC5592704
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Abstract

Summary: Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad comprising increased anion gap metabolic acidosis, ketonemia or ketonuria and normal blood glucose levels <200 mg/dL. This condition is a diagnostic challenge as euglycemia masquerades the underlying diabetic ketoacidosis. Thus, a high clinical suspicion is warranted, and other diagnosis ruled out. Here, we present two patients on regular insulin treatment who were admitted with a diagnosis of EDKA. The first patient had insulin pump failure and the second patient had urinary tract infection and nausea, thereby resulting in starvation. Both of them were aggressively treated with intravenous fluids and insulin drip as per the protocol for the blood glucose levels till the anion gap normalized, and the metabolic acidosis reversed. This case series summarizes, in brief, the etiology, pathophysiology and treatment of EDKA. Learning points: Euglycemic diabetic ketoacidosis is rare. Consider ketosis in patients with DKA even if their serum glucose levels are normal. High clinical suspicion is required to diagnose EDKA as normal blood sugar levels masquerade the underlying DKA and cause a diagnostic and therapeutic dilemma. Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels.

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  • Pramlintide carries a potential risk of severe hypoglycemia if the prandial insulin dose is not appropriately reduced.

    “There is a potential risk of severe hypoglycemia if persons with DM do not appropriately reduce the prandial insulin dosage.1171–1174”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1173]

    The Case presentation and Discussion passages describe insulin-treated patients with euglycemic diabetic ketoacidosis, not hypoglycemia associated with pramlintide. Searches for pramlintide, severe hypoglycemia, and prandial insulin dose reduction found no passage addressing the claimed risk; page numbers were not available in our copy. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Tachyphylaxis often occurs after several years of pramlintide therapy.

    “Tachyphylaxis is often seen after several years of therapy.”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1173]

    The Case presentation and Discussion sections address euglycemic diabetic ketoacidosis and insulin treatment, not pramlintide therapy. Searches for pramlintide, tachyphylaxis, and loss of efficacy after years of treatment found no passage addressing the claim; page numbers were unavailable in our copy. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Nausea is a common adverse effect of pramlintide.

    “Nausea is a common adverse effect.”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1173]

    Case presentation 2 reports nausea, and the Discussion attributes it to an infection rather than a medication. Searches for pramlintide and its adverse effects found no passage addressing whether nausea is a common adverse effect of pramlintide. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

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Authors
Rawla, P., Vellipuram, A. R., Bandaru, S. S., & Pradeep Raj, J.
Affiliations
  • Sovah Health Martinsville (US)
  • Texas Tech University (US)
  • Beth Israel Deaconess Medical Center (US)
  • 4Department of Pharmacology, St John’s Medical College, Bangalore, India
Corresponding author
Rawla, Prashanth
ORCID
Venue
Endocrinology, Diabetes & Metabolism Case Reports
Publisher
Bioscientifica
Published
2017-09-04
Volume
2017
ISSN
2052-0573 (ISSN-L)
DOI
10.1530/edm-17-0081
PMC
PMC5592704
OpenAlex
W2752336798
Cited by
139
References
14
Citations by year
2026: 2 · 2025: 13 · 2024: 27 · 2023: 14 · 2022: 29 · 2021: 17 · 2020: 15 · 2019: 11 · 2018: 6 · 2017: 4 · 2016: 1
FWCI
7.79
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Endocrinology Diabetes and Metabolism Case Reports (publishedVersion, cc-by-nc-nd)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Nephrology › Renal function and acid-base balance
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
euglycemic diabetic ketoacidosis, diabetic ketoacidosis, anion gap metabolic acidosis, ketonuria, ketonemia, normoglycemia, starvation, urinary tract infection, intravenous insulin therapy, fluid resuscitation, diabetes mellitus

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