{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T15:24:50Z","timestamp":1791559490863,"version":"4.3.4"},"reference-count":11,"publisher":"Bioscientifica","issue":"3","license":[{"start":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T00:00:00Z","timestamp":1789948800000},"content-version":"vor","delay-in-days":82,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["journals.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,7,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>Euglycaemic ketoacidosis is characterised by high anion gap metabolic acidosis with elevated serum ketone bodies in the absence of significant hyperglycaemia. Although traditionally associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitors, incretin-based therapies have recently been implicated. Tirzepatide is a dual-acting glucagon-like peptide 1 (GLP-1)\/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. It is an approved treatment for obesity in patients without diabetes mellitus. We present the case of a 51-year-old woman without diabetes, 2 years after sleeve gastrectomy, who presented with nausea, vomiting and abdominal pain after rapid dose escalation of tirzepatide. Laboratory evaluation revealed severe metabolic acidosis (pH 7.01, venous bicarbonate 9.2 mmol\/L), elevated serum ketones (6 mmol\/L) and normal blood glucose (5 mmol\/L), consistent with euglycaemic ketoacidosis. Plasma lactate was normal (1.4 mmol\/L). She was managed with intravenous fluids, insulin infusion and anti-emetics until the symptoms and acidosis resolved. Tirzepatide was discontinued. This case highlights the potential for dual-acting GLP-1\/GIP receptor agonists to increase susceptibility to euglycaemic ketoacidosis in patients without diabetes, particularly in the context of prior bariatric surgery. Clinicians should consider euglycaemic ketoacidosis in patients receiving dual-acting GLP-1\/GIP therapy who present unwell with metabolic acidosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Learning points<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1530\/edm-26-0059","type":"journal-article","created":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T15:05:52Z","timestamp":1790003152000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-2","source":"Crossref","is-referenced-by-count":1,"title":["Euglycaemic ketoacidosis associated with dual-acting GLP-1\/GIP receptor agonist treatment following bariatric surgery"],"prefix":"10.1530","volume":"2026","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6470-5067","authenticated-orcid":true,"given":"Deirdre","family":"Green","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nigel","family":"Glynn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","reference":[{"key":"2026092111054840400_bib1","article-title":"Tirzepatide-induced ketoacidosis in non-diabetic patients","volume":"11","author":"Iqbal","year":"2024","journal-title":"Eur J Case Rep Intern Med"},{"key":"2026092111054840400_bib2","article-title":"Euglycemic ketoacidosis following coadministration of an SGLT2 inhibitor and tirzepatide","volume":"3","author":"Louwagie","year":"2025","journal-title":"JCEM Case Rep"},{"key":"2026092111054840400_bib3","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1056\/NEJMoa2107519","article-title":"Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes","volume":"385","author":"Fr\u00edas","year":"2021","journal-title":"N Engl J Med"},{"key":"2026092111054840400_bib4","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1056\/NEJMoa2206038","article-title":"Tirzepatide once weekly for the treatment of obesity","volume":"387","author":"Jastreboff","year":"2022","journal-title":"N Engl J Med"},{"key":"2026092111054840400_bib5","article-title":"Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: a systematic review and network meta-analysis","volume":"102","author":"Chierici","year":"2022","journal-title":"Int J Surg"},{"key":"2026092111054840400_bib6","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1001\/jamasurg.2025.3089","article-title":"Use of glucagon-like peptide-1 agonists among individuals undergoing bariatric surgery in the US","volume":"160","author":"Kim","year":"2025","journal-title":"JAMA Surg"},{"key":"2026092111054840400_bib7","doi-asserted-by":"crossref","first-page":"2787","DOI":"10.1007\/s11695-021-05263-7","article-title":"Immediate euglycemic diabetic ketoacidosis after gastric bypass in a patient with type II diabetes","volume":"31","author":"Lo","year":"2021","journal-title":"Obes Surg"},{"key":"2026092111054840400_bib8","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1016\/j.numecd.2021.10.003","article-title":"The association between GLP-1 receptor agonist and diabetic ketoacidosis in the FDA adverse event reporting system","volume":"32","author":"Yang","year":"2022","journal-title":"Nutr Metab Cardiovasc Dis"},{"issue":"Supplement 9","key":"2026092111054840400_bib9","first-page":"S40","article-title":"A case of tirzepatide-associated ketoacidosis in a patient without diabetes","volume":"31","author":"Ziyadeh","year":"2025","journal-title":"Endocr Pract"},{"key":"2026092111054840400_bib10","article-title":"Euglycemic diabetic ketoacidosis in the setting of dulaglutide use","volume":"17","author":"Patel","year":"2025","journal-title":"Cureus"},{"key":"2026092111054840400_bib11","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1111\/obr.12199","article-title":"Metabolically healthy and unhealthy obese \u2013 the 2013 stock conference report","volume":"15","author":"Samocha-Bonet","year":"2014","journal-title":"Obes Rev"}],"container-title":["Endocrinology, Diabetes &amp; 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