Case report
The patient was a 57-year-old man who was diagnosed withT2DM at age 50
and treated with very-low-carbohydrate diet in (carbohydrate intake
20–40 g/day) since age 52. Because of the gradual deterioration in
glycemic control and a glycated hemoglobin >7%, his family
physician started SGLT2i, dapagliflozin 5 mg/day. On day 3 after
starting dapagliflozin, he was transported by ambulance to our hospital
because of vomiting, diarrhea, and abdominal pain. On admission, his
body temperature, blood pressure, and heart rate were 36.4°C, 98/60
mmHg, and 78 beats/min, respectively. He weighed 51.0 kg and stood 171
cm tall. His body mass index was 17.6 kg/m2. Arterial
blood gas revealed pH of 7.107, bicarbonate level of 8.1 mmol/L, and
anion gap of 31.9, indicating severe metabolic acidosis. Urinary ketone
bodies of 3+ suggested ketoacidosis, but blood glucose levels were not
markedly elevated at 189 mg/dL. Imaging studies did not identify any
other condition that could cause the acidosis, and he was admitted to
our department with a diagnosis of EDKA. As shown in Table 1, laboratory
findings on admission showed elevated white blood cell counts, slight
hepatic dysfunction and elevated pancreatic exocrine enzymes. After
admission, a large volume of saline was administered intravenously,
followed by continuous administration of glucose and insulin. Blood
glucose levels rose temporarily but gradually decreased, and acidosis
improved (Figure 1). Autoantibodies such as anti-glutamic acid
decarboxylase antibody, islet antigen-2 antibody, and insulin
autoantibody were all negative. Moreover, the insulin secretory capacity
was well maintained with ΔC-peptide immunoreactivity (6 min) of 2.04
ng/mL (2.17–4.21 ng/mL) in the glucagon stimulation test. No diabetic
retinopathy and nephropathy were noted. He resumed eating on day 2 and
was discharged on day 6 after improved glycemic control was confirmed.
At discharge, he was treated with metformin 1,000 mg/day and sitagliptin
50 mg/day. In addition, the diet therapy was introduced at 1,900 kcal
without carbohydrate restriction, i.e., approximately 60% carbohydrate,
15% fat, and 25% protein.