Y HOC TP HO CHI MINH · Mar 15, 2026
SGLT2 inhibitor-associated euglycemic ketoacidosis in an older patient with cardiogenic shock
By Trần NTN, Lâm TV, Ngô LV et al.
Sodium–glucose cotransporter 2 inhibitors (SGLT2i) are currently considered a foundational therapy for heart failure, reducing cardiovascular mortality and hospitalization rates, improving symptoms, and protecting renal function, regardless of whether patients have diabetes. However, alongside these substantial benefits, SGLT2i still carry the potential for adverse effects, including euglycemic ketoacidosis (euglycemic DKA), a rare but serious complication that is easily overlooked. We report the case of a 63-year-old male patient with a history of hypertension and type 2 diabetes who was admitted for acute myocardial infarction. The patient underwent emergency coronary intervention 8 hours after symptom onset and was subsequently transferred to a cardiovascular center for monitoring and inpatient treatment. During treatment, the patient developed ketoacidosis with blood glucose within normal limits, occurring after initiation of SGLT2i as part of the heart failure regimen. This case illustrates a rare but serious adverse effect of SGLT2i, particularly when used in patients with cardiogenic shock or hemodynamic instability. In older adults, the clinical symptoms of ketoacidosis are often vague and atypical, making early recognition and diagnosis difficult. Ketoacidosis is a severe metabolic condition that, when occurring in the setting of acute cardiovascular disease, can exacerbate circulatory failure and increase the risk of death. Therefore, initiation of heart failure medications, particularly SGLT2i, requires careful consideration of timing and hemodynamic status, along with close monitoring for signs of ketoacidosis in high-risk patients, such as older adults and those with diabetes, malnutrition, or prolonged fasting. This cautious approach helps optimize the benefits of SGLT2i therapy while minimizing the risk of adverse metabolic complications.