Case Study: Integrated Management of Type 2 Diabetes Mellitus with Diabetic Ketoacidosis Using SGLT2 Inhibitors and Insulin Therapy

Abstract

This case study describes a 52-year-old male with poorly controlled Type 2 Diabetes Mellitus (T2DM) who presented with mild diabetic ketoacidosis (DKA), recurrent hypoglycemia, and insulin resistance. The patient was initiated on combination therapy involving SGLT2 inhibitors, basal-bolus insulin, and dietary modifications. Over a 12-month follow-up, significant improvements were observed in glycemic control, weight reduction, and quality of life. The case emphasizes the importance of personalized treatment strategies and multidisciplinary care in complex endocrinology cases.

Introduction

Type 2 Diabetes Mellitus (T2DM) remains one of the most prevalent endocrine disorders, affecting over 537 million adults worldwide as of 2021 (IDF). Despite advances in therapeutics, many patients fail to achieve optimal glycemic control due to factors like insulin resistance, poor adherence, and comorbidities.
The introduction of SGLT2 inhibitors has transformed diabetes management by improving glycemic control, cardiovascular outcomes, and renal protection. However, concerns remain regarding euglycemic DKA and long-term safety. This case study highlights the successful application of a multimodal approach in a challenging patient with uncontrolled T2DM.

Patient Information

• Age / Gender: 52-year-old male

• Occupation: Accountant

• Medical History: 8-year history of T2DM, hypertension, dyslipidemia

• Surgical History: None significant

• Family History: Mother with T2DM and CKD

• Social History: Sedentary lifestyle, irregular eating habits, moderate alcohol consumption

• Current Medications: Metformin 1g BD, Glimepiride 2mg OD

• Chief Complaints: Excessive thirst, frequent urination, and fatigue for 2 weeks

Clinical Findings

Symptoms

• Polyuria, polydipsia, fatigue

• Unintentional weight loss (~4 kg in 3 months)

• Mild abdominal discomfort

Physical Examination

• Vitals: BP 146/92 mmHg, HR 104 bpm, Temp 37.5°C

• BMI: 30.8 kg/m² (obese)

• Signs: Mild dehydration, no focal neurological deficits

• Foot Exam: No ulcers or neuropathic changes

Timeline

Initial Diagnosis and Attempted Treatment
In January 2021, the patient was diagnosed with severe opioid use disorder (OUD) and admitted to a 30-day inpatient detoxification program, followed by outpatient counseling. However, the patient relapsed after two months.

Referral for Medication-Assisted Treatment (MAT)
By April 2021, following relapse and the failure of abstinence-based treatment alone, the patient was started on medication-assisted treatment (MAT) using buprenorphine-naloxone (Suboxone) to manage cravings and withdrawal symptoms.

Behavioral Therapy and Counseling Initiated
In June 2021, cognitive behavioral therapy (CBT) and group therapy sessions were initiated. The patient began engaging more actively in treatment and developed effective coping strategies to handle emotional triggers.

Relapse Event
In August 2021, the patient experienced a relapse due to social and familial stressors. The treatment plan was adjusted by increasing the medication dosage and intensifying behavioral therapy to regain control.

Sustained Recovery and Continued Follow-Up
From November 2021 to June 2022, the patient achieved sustained recovery with no further relapses. During this period, the patient also actively participated in work-readiness programs and maintained regular follow-up visits for long-term support.

Diagnostic Assessment

• Laboratory Findings
  On admission, the patient’s blood tests showed severely uncontrolled glycemic levels with a fasting glucose of 276 mg/dL, postprandial glucose of 360 mg/dL, and an HbA1c of 10.8%, indicating poor long-term glucose control. Serum ketones were elevated at 2.4 mmol/L, suggestive of mild diabetic ketoacidosis (DKA). Over the course of treatment, significant improvements were observed. At the 3-month follow-up, fasting glucose reduced to 158 mg/dL, postprandial glucose to 180 mg/dL, and HbA1c dropped to 7.6%. By the 12-month review, the patient achieved near-optimal control with fasting glucose at 102 mg/dL, postprandial glucose at 132 mg/dL, and HbA1c at 6.9%. Serum ketones normalized, and renal function remained stable with a gradual decline in eGFR from 82 ml/min to 78 ml/min, still within the acceptable range.

• Imaging Findings
  An abdominal ultrasound revealed the presence of mild fatty liver, a common finding in patients with long-standing uncontrolled diabetes. An echocardiogram demonstrated normal left ventricular function, indicating the absence of significant diabetic cardiomyopathy or structural heart disease at this stage.

Therapeutic Intervention

Step 1 – Acute Management of DKA

• IV fluids and electrolyte correction

• Insulin infusion protocol

• Gradual shift to subcutaneous insulin

Step 2 – Long-Term Glycemic Control

• Medications:

  • Empagliflozin 10 mg OD (SGLT2 inhibitor)

  • Metformin 1g BD continued

  • Insulin dose titrated and later reduced by 50%

Step 3 – Lifestyle Modifications

• Dietician-supervised low-carb diet

• Structured exercise plan: 30 min/day walking

• Patient education on glucose monitoring

Challenges Faced

• Initial hypoglycemia episodes due to insulin dose miscalculation

• Risk of euglycemic DKA with SGLT2 therapy

• Psychological burden impacting adherence

• High treatment cost initially limited compliance

Follow-Up and Outcomes

Over the 12-month follow-up period, the patient demonstrated significant clinical improvements and better disease control:

Glycemic Control: At baseline, the patient had an HbA1c of 10.8%, which improved to 7.6% at 6 months and further reduced to 6.9% at 12 months, indicating effective long-term glycemic management.

Weight Management: The patient showed a progressive weight reduction from 92 kg at baseline to 87 kg at 6 months and 84 kg at 12 months, reflecting better metabolic control and improved adherence to lifestyle interventions.

Insulin Requirement: Initially requiring 40 units/day of insulin, the patient’s dose was gradually reduced to 24 units/day at 6 months and 18 units/day at 12 months, owing to improved insulin sensitivity and the successful addition of SGLT2 inhibitor therapy.

Quality of Life: At the start of treatment, the patient reported a poor quality of life due to uncontrolled symptoms and frequent complications. Over time, with better glycemic control and weight loss, the patient’s quality of life improved from poor to fair at 6 months and was reported as good at 12 months, with improved energy levels, mood, and daily functioning.

Discussion

• This case highlights the crucial role of SGLT2 inhibitors in the management of complex type 2 diabetes mellitus (T2DM), even in patients with a prior history of diabetic ketoacidosis (DKA). The patient presented with poorly controlled blood glucose levels despite being on basal-bolus insulin therapy and faced challenges such as recurrent hyperglycemia, weight gain, and reduced quality of life. After initiating empagliflozin, an SGLT2 inhibitor, alongside structured lifestyle modifications and close follow-up, the patient demonstrated remarkable improvements in glycemic control, weight reduction, and overall metabolic profile.

• Clinical evidence strongly supports the benefits of SGLT2 inhibitors in similar patient populations. For instance, the EMPA-REG OUTCOME trial by Zinman et al. (NEJM, 2015) demonstrated that empagliflozin not only improves glycemic parameters but also significantly reduces cardiovascular mortality, hospitalization for heart failure, and overall cardiovascular risk in patients with T2DM and high CV risk. This highlights their dual benefit of metabolic regulation and organ protection, making them an effective therapeutic addition to conventional diabetes management.

• Furthermore, the success of this case emphasizes the importance of integrating behavioral interventions with pharmacological therapy. Diabetes self-management education, structured dietary counseling, and continuous patient engagement were crucial in improving medication adherence and ensuring sustainable lifestyle modifications. These non-pharmacological measures complemented the effects of SGLT2 inhibitors, enhancing long-term outcomes.

• However, while SGLT2 inhibitors offer significant clinical benefits, careful monitoring is mandatory, particularly in patients with a previous history of DKA. Euglycemic DKA, though rare, can occur in patients on these agents, making regular ketone monitoring and patient education vital components of therapy. In this case, periodic assessments allowed early detection of potential complications and ensured safe continuation of treatment without adverse effects.

• Overall, this case underscores the importance of a multidisciplinary, individualized, and evidence-based approach in managing complex T2DM cases. By combining modern pharmacotherapy, behavioral strategies, and structured follow-up, clinicians can achieve sustained improvements in glycemic control, cardiovascular health, weight management, and quality of life, even in high-risk patients with prior metabolic complications.

Key Takeaways

• Early intervention with personalized treatment plans improves diabetes control.

• SGLT2 inhibitors are safe and effective when carefully monitored.

• Multidisciplinary care (endocrinologists, dieticians, psychologists) maximizes patient success.

Patient’s Perspective

I struggled for years with my sugars going up and down. The new treatment gave me more energy and helped me lose weight. With education and support, I now manage my diabetes better.

Conclusion

A combination of SGLT2 inhibitors, optimized insulin therapy, and structured lifestyle changes proved highly effective in managing this patient’s uncontrolled type 2 diabetes mellitus (T2DM) and mild DKA, resulting in better glycemic control, weight loss, and metabolic stability.

The case highlights the importance of personalized, evidence-based endocrine care, integrating pharmacological therapies with lifestyle interventions like diet, exercise, and patient education. Close monitoring of glucose, ketone levels, and renal function ensured safety and improved outcomes, demonstrating that a holistic, multidisciplinary approach can achieve sustained remission and enhance overall quality of life.

References

1. Zinman B, et al. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. NEJM. https://doi.org/10.1056/NEJMoa1504720

2. Wiviott SD, et al. (2019). Dapagliflozin and cardiovascular outcomes. NEJM. https://doi.org/10.1056/NEJMoa1812389

3. Zelniker TA, et al. (2019). SGLT2 inhibitors and cardiovascular risk. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.119.044586

4. American Diabetes Association. Standards of Medical Care in Diabetes – 2024. Diabetes Care. https://diabetesjournals.org/care

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