Diabetic Ketoacidosis in Type 2 Diabetes: A Narrative Review of the Presentation That Is Not Expected
DOI:
https://doi.org/10.5281/zenodo.22261260Keywords:
Diabetic ketoacidosis, Euglycaemic ketoacidosis, Type 2 diabetes, SGLT2 inhibitors, Diagnostic delayAbstract
Diabetic ketoacidosis is taught as a complication of type 1 diabetes presenting with marked hyperglycaemia. Neither half of that
description is reliable. People with type 2 diabetes develop ketoacidosis during states of relative insulin deficiency, and a
proportion present with a glucose below the conventional diagnostic threshold of 13.9 mmol/L. Euglycaemic presentations
account for approximately 2 to 3 per cent of ketoacidosis overall, but in a systematic review of 34 published cases associated with
sodium-glucose cotransporter 2 inhibitors, 71 per cent met euglycaemic criteria. The mechanism is understood: urinary glucose
loss lowers plasma glucose, insulin secretion falls, glucagon rises and ketogenesis proceeds while glucose remains near normal.
The clinical problem is that the finding which prompts the diagnosis is absent, and the differential considered first includes sepsis,
lactic acidosis and renal failure. This review sets out the presentation, the precipitants reported, and the limitations of an evidence
base built largely from case reports.
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