A 59-year-old woman developed euglycemic diabetic ketoacidosis shortly after starting the GLP-1 drug dulaglutide, highlighting that this rare but serious complication can occur with GLP-1 agonists, not just SGLT-2 inhibitors.
Normal glucose, dangerous ketonesEuglycemic DKA is easily missed because blood sugar is only modestly elevated — this case was triggered by a GLP-1 drug, a newly recognized risk
What the researchers found
A 59-year-old woman with type 2 diabetes and gastroparesis developed EDKA after initiating dulaglutide:
- She had discontinued SGLT-2 inhibitors one month before the event
- EDKA developed shortly after starting dulaglutide
- Presentation: nausea, vomiting, abdominal pain, modestly elevated glucose
- Laboratory findings confirmed EDKA (metabolic acidosis with ketones despite near-normal blood sugar)
- Successfully treated with intravenous insulin and fluid resuscitation
- Dulaglutide was discontinued, with no recurrence on follow-up
This case challenges the assumption that EDKA is primarily an SGLT-2 inhibitor complication and suggests GLP-1 RAs can trigger it in susceptible patients.
Why it matters
As millions of people start GLP-1 drugs for diabetes and weight loss, awareness of rare but serious complications is essential. EDKA is particularly dangerous because standard blood sugar monitoring won't catch it — glucose levels are only modestly elevated. The combination of gastroparesis (which can reduce food intake and cause vomiting) with a GLP-1 drug (which further suppresses appetite) may create metabolic conditions favoring ketone production. Clinicians need to be alert to this possibility.
How the study worked
This is a single case report describing the clinical presentation, laboratory findings, treatment, and outcome of a patient who developed euglycemic DKA after initiating dulaglutide therapy.
What this study cannot tell us
This is a single case report, which is the weakest level of clinical evidence. The patient had recently discontinued SGLT-2 inhibitors, raising the possibility that residual effects of the prior medication contributed to the EDKA. The temporal association with dulaglutide initiation does not definitively prove causation. Gastroparesis itself can cause nausea and reduced food intake, which could independently contribute to ketosis. No mechanistic explanation for how dulaglutide specifically triggered EDKA is provided.
How to read the evidence
This is a single case report — the lowest level of clinical evidence. While it raises an important safety signal, one case cannot establish causation or quantify risk. It serves as a hypothesis-generating observation that warrants surveillance and further investigation.
When this study was published
Published in 2026, this is a very recent case report reflecting the expanding use of GLP-1 drugs and the need for ongoing pharmacovigilance as these medications reach larger and more diverse patient populations.
The bigger picture
EDKA has been a well-known risk with SGLT-2 inhibitors, leading to FDA warnings and clinical guidelines. This case report extends the concern to GLP-1 receptor agonists. As more patients use GLP-1 drugs — especially in combination with fasting, low-carbohydrate diets, or conditions like gastroparesis — the risk of metabolic ketoacidosis may be higher than previously recognized. This is particularly relevant as GLP-1 drugs are prescribed to increasingly diverse patient populations for weight loss.
Questions still open
- Is the risk of euglycemic DKA with GLP-1 drugs limited to patients with gastroparesis or other conditions that reduce food intake?
- Should patients switching from SGLT-2 inhibitors to GLP-1 drugs have a longer washout period to reduce overlapping EDKA risk?
- Are there ketone monitoring recommendations that should be implemented for high-risk patients starting GLP-1 therapy?
Common questions
What is euglycemic diabetic ketoacidosis?
Should I be worried about this if I take a GLP-1 drug?
Read the original research
Unmasking the risk: euglycemic diabetic ketoacidosis induced by GLP-1 agonist in type 2 diabetes.
Proceedings (Baylor University. Medical Center), 39(1), 163-165
Citation
Adrejiya, Parth; Alhujaily, Ensaf; Abubaker, Mohammad; Dorenbush, Chelsae; Khouzam, Rami. (2026). Unmasking the risk: euglycemic diabetic ketoacidosis induced by GLP-1 agonist in type 2 diabetes.. Proceedings (Baylor University. Medical Center), 39(1), 163-165. https://doi.org/10.1080/08998280.2025.2555778