We describe a case of a middle aged female with history of DM 2 (treated with Metformin and Jardiance) presenting with abdominal pain, nausea, vomiting. She was found to have colitis on CT scan.

She was also found to have metabolic acidosis with ketosis WITHOUT hyperglycemia. Differential for AGMA included

• Glycols
• Oxoproline (acetaminophen metabolite)
• Lactate
• D-lactate
• Methanol
• ASA
• REnal failure
• Ketoacidosis

Patient was diagnosed with Eugylcemic DKA due to SGLT-2 inhibitor, Jardiance or empagliflozin. SGLT-2 work at the proximal convoluted tubule to inhibit reabsorption of glucose and facilitates excretion of glucose into urine. Advantages of SGLT-2 inhibitors include weight loss, reduced blood pressure, reduced CV mortality and improved renal outcomes in those w/ nephropathy. Disadvantages include risk for UTI and GU fungal infections, increased urine output (hypotension/dehydration) and a questionable increased risk for amputation.

Below is a summary for other Anti-glycemic agents that can be used.