Transitioning from insulin to tirzepatide caused rare diabetic ketoalkalosis in insulin-dependent T2DM patient | Research

The takeaway

A 57-year-old insulin-dependent T2DM patient developed diabetic ketoalkalosis (simultaneous ketosis + alkalosis) after switching to tirzepatide, caused by insulin deficiency and vomiting-induced bicarbonate retention, resolving with fluids and insulin.

Mixed acid-base disorder
Transitioning from insulin to tirzepatide caused simultaneous ketosis (from insulin deficiency) and alkalosis (from vomiting)—a rare but dangerous metabolic emergency

What the researchers found

Diabetic ketoalkalosis (simultaneous ketosis + alkalosis). 57-year-old, insulin-dependent T2DM. Switched to tirzepatide. Mechanism: insulin deficiency (ketosis) + vomiting (alkalosis). Resolved with fluids, electrolytes, insulin.

Why it matters

As more insulin-dependent diabetics transition to GLP-1/GIP drugs, mixed acid-base disorders like ketoalkalosis may increase. Recognizing this rare but dangerous complication is essential for safe transition protocols.

How the study worked

Single case report with metabolic analysis.

What this study cannot tell us

Single case. Very rare complication. Other contributing factors possible. Cannot establish incidence.

How to read the evidence

Single case report. Important for clinical awareness of transition risks.

When this study was published

Published in 2025.

The bigger picture

Medication transitions in diabetes carry unique risks. This case reinforces that insulin-dependent patients need gradual tapering—not abrupt switching—to avoid dangerous metabolic emergencies.

Questions still open

How gradually should insulin be tapered when starting tirzepatide?
Should C-peptide be measured before transitioning insulin-dependent patients?
Is ketoalkalosis more common with tirzepatide than other GLP-1 drugs?

Common questions

What is ketoalkalosis?

Ketoalkalosis is a rare metabolic condition where the body produces excess ketones (acids) AND loses acid through vomiting, creating a confusing mix where blood is simultaneously acidic (from ketones) and alkalotic (from vomiting). It is dangerous and requires hospital treatment with IV fluids and insulin.

Is it safe to switch from insulin to tirzepatide?

It can be safe if done gradually. This case shows the danger of stopping insulin too quickly when starting tirzepatide. The insulin deficiency caused ketone production while tirzepatide-induced vomiting removed acid, creating a metabolic emergency. Slow insulin tapering with monitoring is essential.

Read the original research

When the Transition Goes Wrong: A Rare Case of Diabetic Ketoalkalosis After Transitioning to Tirzepatide in Insulin-dependent Type 2 Diabetes.

Cureus, 17(6), e87031

View on PubMed ↗Publisher’s paper ↗

Citation

Sultan, Waleed; Spencer, Jeanne. (2025). When the Transition Goes Wrong: A Rare Case of Diabetic Ketoalkalosis After Transitioning to Tirzepatide in Insulin-dependent Type 2 Diabetes.. Cureus, 17(6), e87031. https://doi.org/10.7759/cureus.87031