Background: SGLT2-inhibitors have been linked to the risk of potential life-threatening euglicemic ketoacidosis (EDKA). The U.S. Food and Drug Administration and the European Medicines Agency issued warnings in 2015 and 2016 respectively on the predisposing factors to the development of DKA in individuals on an SGLT2-i. New predisposing factors to EDKA are still being discovered with the use of SGLT2-i. Case report: We present the case of a 66- year-old; caucasic woman, with type-2 diabetes, treated in the last 12 months; with metformin 1000 mg RP bid and empaglifozin 10 mg once a day. 24 hours before the hospital admission she stopped metformin only. She underwent total knee replacement surgery with spinal anaesthesia. The post-surgical phase was regular, particularly were not registered complications, expecially in terms of fluid loss. Five days after hospital discharge she started to feel tired and fatiguing, had a faintness and a consequent spinal concussion. Taken to the nearest emergency department she appeared confused and polypnoic. The blood tests shown severe metabolic acidosis: pH 6.8, pCO2 8 mmHg, pO2 131 mmHg, HCO3 4,6 mmol/l, lactate 1.7 mmol/l, anion gap: 21,4 mmol/l, glucose 245 mg/dl, creatinine 0,7 mg/dl. Urine: ketons 80 mg/dl. WBC 16.000, emoglobin 15.3 g/dl, C-reactive protein: 40 mg/L, procalcitonin 0.69 ng/ml. She was treated with intravenous infusion of insulin, isotonic saline and glucose solution. Clinical metabolic recovery was achieved in 24 hours. Interrogated, she explained that at home she has been unwell because of local pain, so oral fluid and caloric intake were reduced Conclusions: Episodes of EDKA with SGLT2i use were characterized by lower blood glucose levels and were often caused by precipitating factors. Understanding precipitating factors may help providers better identify patients at risk (e.g. fasting, reduced caloric intake, systemic illness, infection). Because of prolonged action on SGLT-2 transporters, these drugs should be stopped at least 72 hours before scheduled surgery. General practitioners, anesthetists and surgeons demand well defined protocols.
