Euglycemic Diabetic Ketoacidosis: Hidden in Plain Sight.

A recent increase in euglycemic diabetic ketoacidosis (euDKA)-a metabolic state with plasma bicarbonate exceeding 10 mEq/L and blood glucose levels lower than 300 mg/dL-has caught regulators and providers by surprise. It's been more than 40 years since the British Medical Journal expanded the "panorama of diabetic metabolic upsets" with an article on euDKA. Although still rare, the occurrence of euDKA is becoming slightly more common. Unlike the more widely known diabetic ketoacidosis, this condition is devoid of blood glucose elevation. Over two years, the Food and Drug Administration (FDA) Adverse Event Reporting System database linked 73 episodes of euDKA to the use of one of the newest drug classes used in diabetes, the SGLT-2 inhibitors. Subsequently, FDA issued a warning in May 2015 regarding this class of medications. FDA's continued investigation led to a labeling change for this class in December 2015, describing increased risk of euDKA. Health care providers, patients, and caregivers need to increase vigilance, as this seemingly silent complication can be fatal.