# Severe Euglycemic Diabetic Ketoacidosis Requiring Intubation After Tirzepatide and SGLT2 Inhibitor Coadministration in a Patient With Type 1 Diabetes Mellitus From a Large Tertiary Care Centre in Karachi, Pakistan: A Case Report and Brief Review of the Literature

## TL;DR

A patient with type 1 diabetes developed severe euglycemic diabetic ketoacidosis after using tirzepatide and an SGLT2 inhibitor, requiring intubation and intensive treatment.

## Contribution

This case report highlights the risk of severe euDKA in T1DM patients using tirzepatide combined with SGLT2 inhibitors.

## Key findings

- Severe euDKA occurred despite only modest hyperglycemia in a T1DM patient on tirzepatide and empagliflozin.
- The patient required intubation and intravenous bicarbonate therapy due to profound metabolic acidosis.
- Elevated amylase levels suggested possible pancreatic stress related to tirzepatide use.

## Abstract

Euglycemic diabetic ketoacidosis (euDKA) is an uncommon but potentially life‐threatening complication that may arise in patients treated with incretin‐based therapies or Sodium–Glucose Cotransporter‐2 (SGLT2) inhibitors. We report a 41‐year‐old female with Type 1 Diabetes Mellitus (T1DM) who developed severe euDKA after initiating tirzepatide for weight loss while on empagliflozin and basal–bolus insulin therapy. She presented with severe vomiting and profound metabolic acidosis (pH 6.96, bicarbonate 1.5 mmol/L) despite only modest hyperglycemia (glucose 190–200 mg/dL). The severity of acidosis necessitated intubation and intravenous bicarbonate therapy. Laboratory findings revealed elevated amylase (688 U/L), suggesting possible tirzepatide‐associated pancreatic stress. No infection or other precipitating factor was identified. The patient recovered after intensive insulin and fluid replacement. This case highlights the risk of severe euDKA with the administration of tirzepatide in T1DM, particularly in combination with an SGLT2 inhibitor. Clinicians should keep a high index of suspicion for ketoacidosis in such patients despite normal or mildly elevated glucose levels and inform them of early detection of symptoms and sick day management.

Euglycemic diabetic ketoacidosis can occur in patients with T1DM receiving tirzepatide, particularly when combined with SGLT2 inhibitors. This case illustrates a severe presentation requiring intubation and bicarbonate therapy, underscoring the need for vigilant metabolic monitoring, early recognition, and cautious use of dual incretin therapy in insulin‐dependent patients.