When Falls Reveal Acidosis: Unmasking Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor–Induced Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (euDKA) is a rare but serious complication of diabetes mellitus, consisting of about 3% of DKA presentations, and often associated with sodium-glucose co-transporter 2 (SGLT2) inhibitors. Unlike classic DKA, euDKA presents with ketoacidosis despite normal or only mildly elevated blood glucose levels, which can delay diagnosis and treatment. We report the case of a 77-year-old woman with insulin-dependent type 2 diabetes who presented after multiple unprovoked falls that appear to be multifactorial in origin. Initial evaluation revealed dehydration, mild hyperglycemia (glucose 183 mg/dL), elevated anion gap, and positive urine ketones and glucose. Despite treatment with intravenous (IV) fluids and subcutaneous insulin, her condition worsened over the next 24 hours, with progressive acidosis (bicarbonate <10 mmol/L, arterial pH <7.00) and glucose levels remaining below 250 mg/dL. EuDKA was diagnosed, but the patient was unstable and was moved to the ICU. Dapagliflozin was discontinued, and she was treated successfully with IV insulin and aggressive fluid resuscitation. This case illustrates the importance of maintaining a high index of suspicion for euDKA in elderly patients on SGLT2 inhibitors, particularly when presenting with nonspecific symptoms such as confusion or falls. Early recognition, prompt discontinuation of the SGLT2 inhibitor, and appropriate management are critical to improving outcomes.