{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T00:01:33Z","timestamp":1773100893287,"version":"3.50.1"},"reference-count":12,"publisher":"BMJ","issue":"3","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,2,26]]},"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:p>\n                    A man in his 50s with insulin-treated type 2 diabetes mellitus presented with a 1-day history of severe abdominal pain, nausea and vomiting, 15 days after initiation of tirzepatide. On admission, he was severely dehydrated with profound high-anion gap metabolic acidosis (pH 6.8), marked hyperglycaemia and ketosis, consistent with severe diabetic ketoacidosis (DKA), requiring intensive therapy unit admission. He had been treated with insulin for over 10 years, with preserved renal function (estimated glomerular filtration rate 80 mL\/min\/1.73 m\n                    <jats:sup>2<\/jats:sup>\n                    ), haemoglobin A1c of 61 mmol\/mol and no previous history of DKA. Tirzepatide 2.5 mg once a week was commenced, and a telephone review 6 days after the first dose confirmed mild bloating with preserved oral intake and continued insulin use. Following the second dose, gastrointestinal symptoms progressed, resulting in complete inability to tolerate food or fluids for 24 hours prior to admission. During this period, the patient reduced his basal insulin glargine dose from 40 to 20 units for 3\u2009days due to fear of hypoglycaemia. This case highlights the importance of reinforcing sick-day rules and continuation of basal insulin when initiating tirzepatide in insulin-treated patients.\n                  <\/jats:p>","DOI":"10.1136\/bcr-2025-270158","type":"journal-article","created":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T13:15:19Z","timestamp":1773062119000},"page":"e270158","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Severe diabetic ketoacidosis associated with insulin dose reduction after tirzepatide initiation"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-2698-369X","authenticated-orcid":false,"given":"Ei Thinzar","family":"Aung","sequence":"first","affiliation":[{"name":"Diabetes Unit, Swansea Bay University Health Board, Port Talbot, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thinzar","family":"Min","sequence":"additional","affiliation":[{"name":"Diabetes Unit, Diabetes Research Unit, Swansea University Medical School, Swansea Bay University Health Board, Port Talbot, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ye Thurein","family":"Mon","sequence":"additional","affiliation":[{"name":"Diabetes Unit, Swansea Bay University Health Board, Port Talbot, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lucy","family":"Walters","sequence":"additional","affiliation":[{"name":"Neath Port Talbot Hospital, Port Talbot, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,3,9]]},"reference":[{"key":"2026030906150696000_19.3.e270158.1","doi-asserted-by":"crossref","first-page":"1453825","DOI":"10.3389\/fphar.2024.1453825","article-title":"Tirzepatide\u2019s innovative applications in the management of type 2 diabetes and its future prospects in cardiovascular health","volume":"15","author":"Yang","year":"2024","journal-title":"Front Pharmacol"},{"key":"2026030906150696000_19.3.e270158.2","doi-asserted-by":"crossref","DOI":"10.12659\/AJCR.946133","article-title":"Exploring Hypoglycemic Ketoacidosis in Nondiabetic Patients on Tirzepatide: Is Starvation the Culprit?","volume":"25","author":"Bitar","year":"2024","journal-title":"Am J Case Rep"},{"key":"2026030906150696000_19.3.e270158.3","article-title":"Tirzepatide-Induced Ketoacidosis in Non-Diabetic Patients","volume":"11","author":"Iqbal","year":"2024","journal-title":"Eur J Case Rep Intern Med"},{"key":"2026030906150696000_19.3.e270158.4","doi-asserted-by":"crossref","first-page":"1064","DOI":"10.1080\/15563650.2023.2277337","article-title":"Tirzepatide-associated starvation ketoacidosis","volume":"61","author":"Mercer","year":"2023","journal-title":"Clin Toxicol (Phila)"},{"key":"2026030906150696000_19.3.e270158.5","article-title":"Euglycemic Ketoacidosis in a Non-diabetic Patient After Tirzepatide Use: A Cautionary Tale","volume":"17","author":"Singh","year":"2025","journal-title":"Cureus"},{"key":"2026030906150696000_19.3.e270158.6","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(21)02188-7"},{"key":"2026030906150696000_19.3.e270158.7","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(21)01443-4"},{"key":"2026030906150696000_19.3.e270158.8","doi-asserted-by":"crossref","first-page":"1145587","DOI":"10.3389\/fphar.2023.1145587","article-title":"Risk of diabetic ketoacidosis of SGLT2 inhibitors in patients with type 2 diabetes: a systematic review and network meta-analysis of randomized controlled trials","volume":"14","author":"Yang","year":"2023","journal-title":"Front Pharmacol"},{"key":"2026030906150696000_19.3.e270158.9","first-page":"47","article-title":"How to advise on sick day rules","volume":"22","author":"Down","year":"2020","journal-title":"Diabetes Prim Care"},{"key":"2026030906150696000_19.3.e270158.10","unstructured":"US Food and Drug Administration . FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. 2022. Available: https:\/\/www.fda.gov\/drugs\/drug-safety-and-availability\/fda-revises-labels-sglt2-inhibitors-diabetes-include-warnings-about-too-much-acid-blood-and-serious"},{"key":"2026030906150696000_19.3.e270158.11","doi-asserted-by":"crossref","unstructured":"Chaudhury N , Baslas R , Bhamra K . Euglycaemic diabetic ketoacidosis in a patient with type 2 diabetes using tirzepatide. Postgrad Med J 2025. doi:10.1093\/postmj\/qgaf079","DOI":"10.1093\/postmj\/qgaf079"},{"key":"2026030906150696000_19.3.e270158.12","doi-asserted-by":"crossref","DOI":"10.1210\/jcemcr\/luaf028","article-title":"Euglycemic Ketoacidosis Following Coadministration of an SGLT2 Inhibitor and Tirzepatide","volume":"3","author":"Louwagie","year":"2025","journal-title":"JCEM Case Rep"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-270158","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T13:15:22Z","timestamp":1773062122000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-270158"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3]]},"references-count":12,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3,9]]},"published-print":{"date-parts":[[2026,3]]}},"alternative-id":["10.1136\/bcr-2025-270158"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-270158","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3]]}}}