SHM Converge Scientific Abstract ePoster Gallery-A Not-So-Sweet Diagnosis: When Appetite Suppressants Work Too Well

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This case report describes a 62-year-old woman with type 2 diabetes who developed life-threatening euglycemic diabetic ketoacidosis (EDKA) after starting tirzepatide while already taking dapagliflozin. She had recently switched from dulaglutide to tirzepatide and then developed a week of poor oral intake, polydipsia, polyuria, palpitations, volume depletion, tachycardia, and fruity breath odor. Despite a normal blood glucose of 107 mg/dL, labs showed severe metabolic acidosis with bicarbonate 5 mmol/L, anion gap 31, and venous pH 7.1; imaging was unrevealing.<br /><br />EDKA is a form of diabetic ketoacidosis that occurs without marked hyperglycemia. It is a known complication of SGLT-2 inhibitors like dapagliflozin, which increase urinary glucose excretion and can promote ketosis when insulin levels fall. GLP-1 receptor agonists such as semaglutide and tirzepatide have also rarely been linked to EDKA, likely through marked appetite suppression and reduced carbohydrate intake. In this patient, the combination of tirzepatide-induced appetite suppression and dapagliflozin likely triggered ketosis.<br /><br />She was admitted to the ICU and treated with IV fluids, bicarbonate, and insulin, while her diabetes medications were held. Her anion gap normalized and she improved enough to tolerate oral intake. She was discharged on metformin, with both tirzepatide and dapagliflozin stopped initially. Later, tirzepatide was successfully reintroduced with metformin alone without recurrence.<br /><br />The authors conclude that EDKA can occur with either SGLT-2 inhibitors alone or, more rarely, GLP-1 agonists, and may be especially dangerous when these drugs are combined. Clinicians should watch for this complication as combination therapy becomes more common.

Asset Subtitle

Jacob Momberger

Meta Tag

Author List Jacob Momberger, John Gerstenberger

Category Clinical Vignettes

Concept Euglycemic Diabetic Ketoacidosis

Concept Diagnostic Criteria

Concept Ketonemia

Concept Anion Gap

Concept Metabolic Acidosis

Distinguished Non-Finalist

Presenter Organization University of Utah School of Medicine

Presenting Author Jacob Momberger

Track Adult

Keywords

euglycemic diabetic ketoacidosis

EDKA

tirzepatide

dapagliflozin

SGLT-2 inhibitor

GLP-1 receptor agonist

type 2 diabetes

anion gap metabolic acidosis

poor oral intake

insulin therapy

Euglycemic Diabetic Ketoacidosis

Diagnostic Criteria

Ketonemia

Anion Gap

Metabolic Acidosis