Euglycemic DKA: What It Is, Why It Happens, and How It’s Managed

When you think of diabetic ketoacidosis, you probably imagine very high blood sugar, confusion, and rapid breathing. But euglycemic DKA, a life-threatening condition where ketoacidosis develops despite normal or only slightly elevated blood glucose levels. Also known as normoglycemic DKA, it’s not rare—it’s underdiagnosed, especially in people taking newer diabetes drugs like SGLT2 inhibitors. This isn’t just a technical twist in diabetes care. It’s a silent danger that can catch patients and doctors off guard because the usual warning sign—high blood sugar—is missing.

SGLT2 inhibitors, a class of medications used to lower blood sugar by making the kidneys flush out glucose. Also known as gliflozins, they include drugs like empagliflozin, dapagliflozin, and canagliflozin. These drugs work great for weight loss and heart protection, but they can also mask the early signs of DKA. When insulin levels drop—even slightly—your body starts burning fat for fuel. That produces ketones. Normally, high blood sugar would trigger you to drink water and get help. But with SGLT2 inhibitors, your kidneys are already flushing out sugar, so your glucose levels stay near normal while ketones build up. You feel awful, but your glucometer says you’re fine. That’s the trap.

People with type 1 diabetes are most at risk, but it’s also showing up in type 2 patients, especially those under stress, sick, or cutting carbs too hard. Surgery, infection, or even skipping meals can push someone into euglycemic DKA. The symptoms? Nausea, vomiting, abdominal pain, fatigue, fast breathing. It looks like the flu. Or food poisoning. But if you’re on an SGLT2 inhibitor and feel this way, don’t wait for your sugar to spike. Check your ketones with a urine strip or blood meter. If they’re high, get help now.

Insulin deficiency, the root cause of all DKA, whether blood sugar is high or normal. In classic DKA, you’re out of insulin and your blood sugar is sky-high. In euglycemic DKA, you’re still low on insulin—but the drug you’re taking is hiding the symptom. That’s why treatment is different. You can’t just give insulin and expect sugar to drop fast. You need fluids, electrolytes, and insulin—but you also need to stop the SGLT2 inhibitor and monitor ketones closely. Hospitals are getting better at recognizing this, but many ERs still miss it because they’re looking for high glucose.

This isn’t a theory. It’s a real, documented risk. The FDA has issued warnings. Studies show it happens in up to 1 in 1,000 patients on these drugs. And it’s not going away. More people are using SGLT2 inhibitors because they’re effective. But that means more cases of euglycemic DKA will pop up—and more people will be surprised when their sugar looks normal but they’re in acidosis.

The posts below cover related issues you might not connect at first glance: how certain diabetes drugs interact with other meds, what happens when insulin therapy changes, and how side effects from common treatments can hide deeper problems. You’ll find real-world advice on spotting hidden risks, managing drug interactions, and knowing when to push for testing—even when numbers look fine. This isn’t about memorizing lab values. It’s about understanding how your body reacts when the usual signals are turned off.