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.