Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy

A 51-year-old woman with type 2 diabetes mellitus developed euglycemic diabetic ketoacidosis (euDKA) in the post-operative setting after robotic-assisted sleeve gastrectomy. She developed tachycardia on post-operative day (POD) 1 before developing altered mental status and tachypnea on POD 2. The diagnosis was ultimately made by discovering ketonuria in the setting of anion gap metabolic acidosis despite repeatedly normal blood glucose levels. Pre-operatively, her blood glucose levels were managed with sodium-glucose co-transporter-2 (SGLT-2) inhibitor-containing combination pill, Invokamet®, as well as basal-bolus insulin regimen consisting of aspart (NovoLog®) and glargine-lixisenatide (Soliqua®). SLGT-2 inhibitors have been associated with an increased risk of euDKA, particularly in the context of severe bodily stressors such as surgery. EuDKA is a difficult diagnosis to make because of the lack of characteristic severe hyperglycemia that is typical of DKA. Clinicians should be mindful of euDKA in the post-operative setting of diabetic patients, particularly for those on SGLT-2 inhibitors.