International medical case reports journalOct 11, 2026

Severe Diabetic Ketoacidosis with Normal Blood Sugar After Poor Eating Linked to Semaglutide, Despite Stopping Empagliflozin: A Case Report

GLP-1 Therapies Weekly Brief ↗PubMed ↗DOI ↗OA ↗

Updated Oct 12, 2026

Abstract

A 68-year-old woman with type 2 diabetes presented with venous pH 7.13 and a glucose level of 132 mg/dL, indicating potential diabetic ketoacidosis despite near-normal blood sugar.

Euglycemic diabetic ketoacidosis (EDKA) may occur even when blood glucose levels are normal.
The patient experienced gastrointestinal symptoms and a significant decline in oral intake following the initiation of semaglutide.
Key laboratory findings included an anion gap of 26 mmol/L and elevated beta-hydroxybutyrate at 99.5 mg/dL.
Intravenous fluids, insulin, and electrolyte replacement led to improvement in the patient's condition.
The case suggests a potential link between semaglutide use and the development of EDKA, highlighting the need for careful monitoring.

Simplified

Euglycemic diabetic ketoacidosis (EDKA) may be overlooked when serum glucose is near normal. A 68-year-old woman with long-standing type 2 diabetes developed approximately three weeks of nausea, intermittent vomiting and diarrhea, and minimal oral intake after semaglutide initiation at 0.25 mg once weekly for four weeks followed by 0.5 mg once weekly. Patient and family medication reconciliation indicated that she had stopped empagliflozin, metformin, and pioglitazone approximately two weeks before presentation but continued semaglutide, with the last dose approximately eight days before admission. She presented with weakness, dyspnea, slowed speech, and disorientation. Initial testing showed glucose 132 mg/dL, venous pH 7.13, bicarbonate 9 mmol/L, anion gap 26 mmol/L, and beta-hydroxybutyrate 99.5 mg/dL. She improved with intravenous crystalloid, dextrose-containing fluids, insulin infusion, and electrolyte replacement. The temporal association is consistent with a clinically plausible contribution from semaglutide-associated gastrointestinal intolerance and carbohydrate depletion to EDKA despite reported prior empagliflozin discontinuation. Normal glucose should not delay ketone and acid-base testing when compatible symptoms and poor intake are present.

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Severe Diabetic Ketoacidosis with Normal Blood Sugar After Poor Eating Linked to Semaglutide, Despite Stopping Empagliflozin: A Case Report

Abstract

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