Euglycemic diabetic ketoacidosis: Rising incidence, diagnostic delays, and the impact of SGLT2 inhibitors in hospitalized patients

In the setting of growing use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), little is known about the prevalence and impact of euglycemic diabetic ketoacidosis (eDKA). We performed a retrospective analysis on patients with DKA in the Catholic Health Initiatives-Omaha Health system from 2018 to 2023. Among the 510 patients meeting inclusion criteria; 455 (89.2%) had traditional DKA and 55 (10.8%) had eDKA. SGLT2i use was more likely in eDKA patients (44.4% vs. 0.03%). Compared with traditional DKA, those with eDKA had a significantly longer time to diagnosis (388 vs. 166 min, p < .001) and duration of DKA (2772 vs. 2005 min, p = .007). However, intensive care unit (ICU) and hospital length of stay (LOS) were similar between both DKA groups (171 vs. 170 h; 3.43 vs. 3.37 days, respectively). The unique biochemical profile of eDKA likely delays diagnosis and treatment, ultimately leading to similar LOS despite eDKA patients having lower Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Because the proportion of eDKA is rising, hospitalists must have a heightened awareness of eDKA as SGLT2i use increases.