Sodium-glucose cotransporter-2 inhibitor-associated euglycemic diabetic ketoacidosis in an adolescent with type 2 diabetes

Youth-onset type 2 diabetes (T2D) is increasing, prompting expanded use of pharmacotherapies previously approved only for adults. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, approved for pediatric use in 2023, improve glycemic control by promoting glucosuria, but they carry a known risk of euglycemic diabetic ketoacidosis (DKA) in adults. We describe a unique pediatric case of SGLT2 inhibitor-associated euglycemic DKA in a 12-year-old female with T2D. The patient developed DKA with normal glucose shortly after initiating an SGLT2 inhibitor, leading to diagnostic uncertainty and recognition only after exclusion of more common etiologies. She was successfully treated with intravenous insulin and fluids with resolution of DKA and subsequently transitioned to subcutaneous insulin therapy. This case underscores that euglycemic DKA can occur in youth receiving SGLT2 inhibitors, particularly during puberty when physiologic insulin resistance may heighten risk, and that subtle presentations can complicate early recognition if clinicians rely on hyperglycemia alone. As SGLT2 inhibitors enter broader pediatric use, heightened diagnostic vigilance, guided assessment of ketones and acid-base status in symptomatic patients, and patient and family education are essential to ensure safe use in children and adolescents with T2D.