A 47 yr old man with known diabetes presented with euglycaemic ketoacidosis following the recent commencement of empaglifozin. In 2006, he was diagnosed with Type 2 diabetes. He was overweight (BMI 35 kg/m2) and his mother had Type 2 diabetes. He was started on insulin 6-12 months (plus metformin) after diagnosis due to poor control.
In 2011, he had his first episode of DKA (pH 7.16) in the setting of decreased oral intake and omitting insulin for 2 days. In 2013, he had another episode of severe DKA (pH 6.89). Autoantibodies were elevated (islet cell Ab: 12.8 U/ml [<0.8 U/ml]). He cannot recall being informed of the diagnosis of LADA or Type 1 diabetes.
In 2016, he presented to a private endocrinologist with poor glycaemic control (HbA1C 10%) and wanting to lose weight. The prior history of DKA was not obtained. He was advised to:
Three days after he instituted these changes, he became lethargic and fatigued. On day 6, he developed nausea and vomiting and presented to ED with a glucose of 8 mmol/L, pH 7.14. There was no clinical evidence of sepsis. He was treated for euglycaemic DKA with IV dextrose and insulin. He was discharged on day 4 on subcutaneous insulin.