{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T22:36:46Z","timestamp":1790807806144,"version":"4.1.0"},"reference-count":28,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,3,29]],"date-time":"2022-03-29T00:00:00Z","timestamp":1648512000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,3,29]],"date-time":"2022-03-29T00:00:00Z","timestamp":1648512000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J Med Case Reports"],"published-print":{"date-parts":[[2022,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>We describe a case report of a patient with type 2 diabetes on sodium-glucose cotransporter 2 inhibitor and metformin therapy fasting for Ramadan (a holy month observed in the Islamic nation) diagnosed with euglycemic diabetic ketoacidosis.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Case presentation<\/jats:title>\n                <jats:p>The patient was a 51-year-old Moroccan male with history of type 2 diabetes mellitus on dapagliflozin and metformin. He presented with abdominal pain, vomiting, loss of appetite, and shortness of breath. He observed Ramadan month by fasting an average of 14\u00a0hours daily for 30\u00a0days. The patient was admitted with severe metabolic acidosis with a high anion gap and positive ketonuria in the setting of serum glucose of 13.5 mmol\/L (243 mg\/dL).<\/jats:p>\n                <jats:p>The patient was rehydrated and started on insulin infusion according to the diabetic ketoacidosis protocol following the diagnosis of euglycemic diabetic ketoacidosis.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Dapagliflozin is associated with euglycemic diabetic ketoacidosis in the setting of prolonged fasting. Counseling and possible medication adjustment should be added to clinical practice in those planning to decrease caloric intake through dedicated fasting including Ramadan or weight-loss-directed behavioral modifications, especially if taking sodium-glucose cotransporter 2 inhibitors.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s13256-022-03347-1","type":"journal-article","created":{"date-parts":[[2022,3,28]],"date-time":"2022-03-28T23:04:02Z","timestamp":1648508642000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Euglycemic diabetic ketoacidosis induced by sodium-glucose cotransporter 2 inhibitor in the setting of prolonged fasting: a case report"],"prefix":"10.1186","volume":"16","author":[{"given":"Abrar","family":"Alkatheeri","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eiman","family":"Alseddeeqi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2022,3,29]]},"reference":[{"issue":"12","key":"3347_CR1","doi-asserted-by":"publisher","first-page":"2739","DOI":"10.2337\/dc06-9916","volume":"29","author":"AE Kitabchi","year":"2006","unstructured":"Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(12):2739\u201348. https:\/\/doi.org\/10.2337\/dc06-9916.","journal-title":"Diabetes Care"},{"issue":"9","key":"3347_CR2","doi-asserted-by":"publisher","first-page":"1687","DOI":"10.2337\/dc15-0843","volume":"38","author":"AL Peters","year":"2015","unstructured":"Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015;38(9):1687\u201393. https:\/\/doi.org\/10.2337\/dc15-0843.","journal-title":"Diabetes Care"},{"key":"3347_CR3","unstructured":"Plewa MC, Bryant M, King-Thiele R. Euglycemic Diabetic Ketoacidosis. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554570\/."},{"issue":"5866","key":"3347_CR4","doi-asserted-by":"publisher","first-page":"578","DOI":"10.1136\/bmj.2.5866.578","volume":"2","author":"JF Munro","year":"1973","unstructured":"Munro JF, Campbell IW, McCuish AC, Duncan LJ. Euglycaemic diabetic ketoacidosis. Br Med J. 1973;2(5866):578\u201380.","journal-title":"Br Med J"},{"key":"3347_CR5","doi-asserted-by":"publisher","first-page":"110668","DOI":"10.1016\/j.nut.2019.110668","volume":"72","author":"A Larroumet","year":"2020","unstructured":"Larroumet A, Camoin M, Foussard N, Alexandre L, Mesli S, Redonnet I, Baillet-Blanco L, Rigalleau V, Mohammedi K. Euglycemic ketoacidosis induced by therapeutic fasting in a non-diabetic patient. Nutrition. 2020;72:110668. https:\/\/doi.org\/10.1016\/j.nut.2019.110668.","journal-title":"Nutrition"},{"issue":"1","key":"3347_CR6","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1007\/s11606-008-0829-0","volume":"24","author":"F Joseph","year":"2009","unstructured":"Joseph F, Anderson L, Goenka N, Vora J. Starvation-induced true diabetic euglycemic ketoacidosis in severe depression. J Gen Intern Med. 2009;24(1):129\u201331. https:\/\/doi.org\/10.1007\/s11606-008-0829-0.","journal-title":"J Gen Intern Med"},{"issue":"5","key":"3347_CR7","first-page":"62","volume":"112","author":"R Legaspi","year":"2015","unstructured":"Legaspi R, Narciso P. Euglycemic diabetic ketoacidosis due to gastroparesis, a local experience. J Ark Med Soc. 2015;112(5):62\u20133.","journal-title":"J Ark Med Soc"},{"issue":"3","key":"3347_CR8","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1111\/j.1447-0756.2008.00720.x","volume":"34","author":"RX Guo","year":"2008","unstructured":"Guo RX, Yang LZ, Li LX, Zhao XP. Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy. J Obstet Gynaecol Res. 2008;34(3):324\u201330. https:\/\/doi.org\/10.1111\/j.1447-0756.2008.00720.x.","journal-title":"J Obstet Gynaecol Res"},{"key":"3347_CR9","unstructured":"FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. (2015, May 15). U.S Food and Drug Administration. Retrieved October 1, 2022, from https:\/\/www.fda.gov\/drugs\/drug-safety-and-availability\/fda-revises-labels-sglt2-inhibitors-diabetes-include-warnings-about-too-much-acid-blood-and-serious."},{"issue":"6","key":"3347_CR10","doi-asserted-by":"publisher","first-page":"499","DOI":"10.14740\/jocmr2976w","volume":"9","author":"A Bashier","year":"2017","unstructured":"Bashier A, Khalifa AA, Rashid F, Abdelgadir EI, Al Qaysi AA, Ali R, Eltinay A, Nafach J, Alsayyah F, Alawadi F. Efficacy and safety of SGLT2 inhibitors in reducing glycated hemoglobin and weight in emirati patients\u00a0with\u00a0type 2 diabetes. J Clin Med Res. 2017;9(6):499\u2013507. https:\/\/doi.org\/10.14740\/jocmr2976w.","journal-title":"J Clin Med Res"},{"issue":"2","key":"3347_CR11","doi-asserted-by":"publisher","first-page":"208","DOI":"10.1093\/ndt\/gfy407","volume":"34","author":"P Sarafidis","year":"2019","unstructured":"Sarafidis P, Ferro CJ, Morales E, et al. SGLT-2 inhibitors and GLP-1 receptor agonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. A consensus statement by the EURECA-m and the DIABESITY working groups of the ERA-EDTA. Nephrol Dial Transplant. 2019;34(2):208\u201330.","journal-title":"Nephrol Dial Transplant"},{"issue":"22","key":"3347_CR12","doi-asserted-by":"publisher","first-page":"2117","DOI":"10.1056\/NEJMoa1504720","volume":"373","author":"B Zinman","year":"2015","unstructured":"Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, Mattheus M, Devins T, Johansen OE, Woerle HJ, Broedl UC, Inzucchi SE, EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117\u201328. https:\/\/doi.org\/10.1056\/NEJMoa1504720.","journal-title":"N Engl J Med"},{"key":"3347_CR13","doi-asserted-by":"publisher","first-page":"1687","DOI":"10.2337\/dc15-0843","volume":"38","author":"AL Peters","year":"2015","unstructured":"Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015;38:1687\u201393.","journal-title":"Diabetes Care"},{"issue":"3","key":"3347_CR14","doi-asserted-by":"publisher","first-page":"153","DOI":"10.11622\/smedj.2021029","volume":"62","author":"KT Tan","year":"2021","unstructured":"Tan KT. Three cases of euglycaemic diabetic ketoacidosis related to the use of sodium-glucoseco-transporter-2 inhibitors and calorie restriction. Singapore Med J. 2021;62(3):153\u20134.","journal-title":"Singapore Med J"},{"issue":"9","key":"3347_CR15","doi-asserted-by":"publisher","first-page":"1638","DOI":"10.2337\/dc15-1380","volume":"38","author":"J Rosenstock","year":"2015","unstructured":"Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care. 2015;38(9):1638\u201342. https:\/\/doi.org\/10.2337\/dc15-1380.","journal-title":"Diabetes Care"},{"key":"3347_CR16","doi-asserted-by":"publisher","first-page":"e2924","DOI":"10.1002\/dmrr.2924","volume":"33","author":"JE Blau","year":"2017","unstructured":"Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data. Diabetes Meta Res Rev. 2017;33:e2924.","journal-title":"Diabetes Meta Res Rev."},{"key":"3347_CR17","first-page":"987","volume":"19","author":"MH Rouhani","year":"2014","unstructured":"Rouhani MH, Azadbakht L. Is Ramadan fasting related to health outcomes? A review on the related evidence? J Res Med Sci. 2014;19:987\u201392.","journal-title":"J Res Med Sci"},{"issue":"3","key":"3347_CR18","doi-asserted-by":"publisher","first-page":"389","DOI":"10.5811\/cpcem.2020.4.46056","volume":"4","author":"RA Mendelsohn","year":"2020","unstructured":"Mendelsohn RA, Taveras AN, Mazer BA, Clayton LM. Euglycemic diabetic ketoacidosis precipitated by SGLT-2 inhibitor use, pericarditis, and fasting: a case report. Clin Pract Cases Emerg Med. 2020;4(3):389\u201392. https:\/\/doi.org\/10.5811\/cpcem.2020.4.46056.","journal-title":"Clin Pract Cases Emerg Med"},{"issue":"4","key":"3347_CR19","doi-asserted-by":"publisher","first-page":"507","DOI":"10.1016\/j.metabol.2015.12.007","volume":"65","author":"EA Nyenwe","year":"2016","unstructured":"Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: an update of its etiology, pathogenesis and management. Metabolism. 2016;65(4):507\u201321. https:\/\/doi.org\/10.1016\/j.metabol.2015.12.007.","journal-title":"Metabolism"},{"key":"3347_CR20","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1111\/jdi.12401","volume":"7","author":"W Ogawa","year":"2016","unstructured":"Ogawa W, Sakaguchi K. Euglycemic diabetic ketoacidosis induced by SGLT2 inhibitors:\u00a0possible mechanism\u00a0and contributing factors. J Diabetes Investig. 2016;7:135\u20138.","journal-title":"J Diabetes Investig."},{"issue":"5","key":"3347_CR21","doi-asserted-by":"publisher","first-page":"1190","DOI":"10.2337\/db15-1356","volume":"65","author":"E Ferrannini","year":"2016","unstructured":"Ferrannini E, Baldi S, Frascerra S, Astiarraga B, Heise T, Bizzotto R, Mari A, Pieber TR, Muscelli E. Shift to fatty substrate utilization in response to sodium-glucose cotransporter 2 inhibition in subjects without diabetes and patients with type 2 diabetes. Diabetes. 2016;65(5):1190\u20135. https:\/\/doi.org\/10.2337\/db15-1356.","journal-title":"Diabetes"},{"issue":"1","key":"3347_CR22","doi-asserted-by":"publisher","first-page":"83","DOI":"10.1016\/j.dsx.2016.06.028","volume":"11","author":"MH Alabbood","year":"2017","unstructured":"Alabbood MH, Ho KW, Simons MR. The effect of Ramadan fasting on glycaemic control in insulin dependent diabetic patients: a literature review. Diabetes Metab Syndrome Clin Res Rev. 2017;11(1):83\u20137. https:\/\/doi.org\/10.1016\/j.dsx.2016.06.028.","journal-title":"Diabetes Metab Syndrome Clin Res Rev"},{"issue":"1","key":"3347_CR23","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1056\/NEJMc052709","volume":"354","author":"S Pankaj","year":"2006","unstructured":"Pankaj S, William L. Ketoacidosis during a low-carbohydrate diet. N Engl J Med. 2006;354(1):97\u20138. https:\/\/doi.org\/10.1056\/NEJMc052709.","journal-title":"N Engl J Med"},{"issue":"7","key":"3347_CR24","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.16085","volume":"13","author":"E Tsutsui","year":"2021","unstructured":"Tsutsui E, Hoshina Y, Homma H. Sodium-glucose cotransporter-2 inhibitor-induced euglycemic diabetic ketoacidosis followed by excessively low carbohydrate diet. Cureus. 2021;13(7): e16085. https:\/\/doi.org\/10.7759\/cureus.16085.","journal-title":"Cureus"},{"issue":"3","key":"3347_CR25","doi-asserted-by":"publisher","first-page":"587","DOI":"10.1016\/j.mcna.2016.12.011","volume":"101","author":"M Fayfman","year":"2017","unstructured":"Fayfman M, Pasquel FJ, Umpierrez GE. Management of hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Med Clin North Am. 2017;101(3):587\u2013606. https:\/\/doi.org\/10.1016\/j.mcna.2016.12.011.","journal-title":"Med Clin North Am"},{"key":"3347_CR26","unstructured":"UK Medicines and Healthcare Products Regulatory Agency\u00a0SGLT2 inhibitors:updated advice on the risk of diabetic ketoacidosis. Available at:\u00a0https:\/\/www.gov.uk\/drug-safety-update\/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis.\u00a0Accessed November 7, 2021."},{"key":"3347_CR27","unstructured":"Australian and New Zealand College of Anaesthetists\u00a0Alert: Severe euglycaemic ketoacidosis with SGLT2 inhibitor use in the perioperative period. Available at:\u00a0https:\/\/www.anzcagetattachment.edu.au\/\/d16e5295-41da-44a2-a21b-3bce2e0e10ae\/Periprocedural-Diabetic-Ketoacidosis-(DKA)-with-SGLT2-Inhibitor-Use. Accessed Novemeber 11, 2021."},{"issue":"1","key":"3347_CR28","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1111\/jdi.13160","volume":"11","author":"Committee on the Proper Use of SGLT2 Inhibitors","year":"2020","unstructured":"Committee on the Proper Use of SGLT2 Inhibitors. Recommendations on the proper use of SGLT2 inhibitors. J Diabetes Investig. 2020;11(1):257\u201361. https:\/\/doi.org\/10.1111\/jdi.13160.","journal-title":"J Diabetes Investig"}],"container-title":["Journal of Medical Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13256-022-03347-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13256-022-03347-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13256-022-03347-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,3,28]],"date-time":"2022-03-28T23:09:45Z","timestamp":1648508985000},"score":1,"resource":{"primary":{"URL":"https:\/\/jmedicalcasereports.biomedcentral.com\/articles\/10.1186\/s13256-022-03347-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,3,29]]},"references-count":28,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2022,12]]}},"alternative-id":["3347"],"URL":"https:\/\/doi.org\/10.1186\/s13256-022-03347-1","relation":{},"ISSN":["1752-1947"],"issn-type":[{"value":"1752-1947","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,3,29]]},"assertion":[{"value":"17 November 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 February 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 March 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"138"}}