Rationale: Diabetic ketoacidosis is rarely observed when the blood glucose level is <250 mg/dL. This is referred to as euglycemic diabetic ketoacidosis (EDKA). EDKA can present diagnostic and management challenges for physicians, especially when dealing with unusual triggers such as glucagon-like peptide 1 (GLP1) receptor agonists and sodium-glucose co-transporter 2 inhibitors. With this case report, we wanted to raise the knowledge and understanding of EDKA and its triggering factors. Patient concerns: A 45-year-old man was admitted to hospital for epigastric pain, loss of appetite, and vomiting 3 days after the initiation of dulaglutide. The results of laboratory examination showed EDKA. Diagnoses: The patient was diagnosed with EDKA after the initiation of GLP1 receptor agonists. Interventions: Intravenous fluid and insulin infusion were immediately started. Outcome: The patient was discharged after treatment Lessons: In this case report describes the use of GLP1 receptor agonists along with Sodium-glucose co-transporter 2 inhibitors in type 2 diabetes patients whose extreme restriction of carbohydrate intake may have triggered EDKA. Therefore, physicians should use diabetes medications in a stepwise manner and advise their patients not to over-restrict their carbohydrate intake while they are being treated with GLP1 receptor agonists.

Background: Travel has become an integral part of Saudi life. People with diabetes face many challenges while travelling that can have detrimental effects on glycaemic control. However, no previous studies have investigated pre-travel counselling in Saudi Arabia. This study aims to assess the knowledge, attitudes and practices of primary health care (PHC) physicians regarding pre-travel counselling for patients with type 2 diabetes. Methods: This cross-sectional study was conducted in PHC centres under the Ministry of Health in Riyadh, Saudi Arabia, during the period 2018–2019. A cluster multistage random sampling technique was used to recruit physicians. The data were collected through a self-administered questionnaire. Results: Three hundred and eighty-five primary health care physicians were recruited. This study showed that more than half (57.9%) of PHC physicians had poor knowledge scores. Additionally, the following characteristics were significantly associated with poor knowledge: being younger in age, being male, being Saudi, being a general practitioner, and having limited (0–5 years) experience. A total of 183 (47.5%) subjects showed disagreement attitudes towards the importance of pre-travel counselling among patients with diabetes. Furthermore, these disagreement attitudes were significantly associated with being older and having more years of experience. The majority (62.6%) of the physicians had poor practice scores. Poor practices were detected among physicians who were younger, male, and Saudi and who had a general practitioner specialty and degree. Conclusions: It could be concluded that a gap was detected in the knowledge and practices of primary health care physicians regarding pre-travel counselling for people with type 2 diabetes. Therefore, it is necessary to create easily accessible travel medicine education programmes for Saudi PHC providers to improve the management of travellers with diabetes.

Rationale: Gastrointestinal symptoms are most commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, gastrointestinal symptoms may persist after DKA is resolved. Patient concerns: A 22-year-old female was admitted to hospital for epigastric pain and persistent vomiting. The results of laboratory examination showed fungal esophagitis complicated by DKA. Diagnosis: The patient was diagnosed with DKA associated with ascariasis and fungal esophagitis Outcome: The patient was discharged after treatment Lessons: In this case, despite the correction of metabolic acidosis, persistent nausea, vomiting and dysphagia can be a sign of esophagitis in patients with type 1 diabetes. Therefore, physicians should be aware of fungal infections associated with type 1 diabetes.

Background: Acute pancreatitis (AP) is a potentially life-threatening condition that can result from various aetiologies. While gallstones and alcohol consumption are the most common causes, medications can also induce AP. In the absence of a clear cause, drug-induced acute pancreatitis (DIAP) may pose challenges for clinicians. This is especially true when addressing unusual and rare causes such as glucagon-like peptide-1 receptor agonists. Case Presentation: A 41-year-old Saudi man was admitted to the hospital with epigastric pain after receiving subcutaneous semaglutide for weight loss. Laboratory test results revealed AP. Conclusions: In conclusion, semaglutide-induced acute pancreatitis is a rare but serious adverse effect. Clinicians should be aware of this potential adverse effect, particularly in patients without a history of diabetes mellitus who are using the drug for weight loss. Early recognition and discontinuation of the drug are crucial for the management of this condition.

Background: Travel has become an integral part of Saudi life. People with diabetes face many challenges while travelling that can have detrimental effects on glycaemic control. However, no previous studies have investigated pre-travel counselling in Saudi Arabia. This study aims to assess the knowledge, attitudes and practices of primary health care (PHC) physicians regarding pre-travel counselling for patients with type 2 diabetes.Methods: This cross-sectional study was conducted in PHC centres under the Ministry of Health in Riyadh, Saudi Arabia, during the period 2018-2019. A cluster multistage random sampling technique was used to recruit physicians. The data were collected through a self-administered questionnaire.Results: Three hundred and eighty-five primary health care physicians were recruited. This study showed that more than half (57.9%) of PHC physicians had poor knowledge scores. Additionally, the following characteristics were significantly associated with poor knowledge: being younger in age, being male, being Saudi, being a general practitioner, and having limited (0-5 years) experience. A total of 183 (47.5%) subjects showed disagreement attitudes towards the importance of pre-travel counselling among patients with diabetes. Furthermore, these disagreement attitudes were significantly associated with being older and having more years of experience. The majority (62.6%) of the physicians had poor practice scores. Poor practices were detected among physicians who were younger, male, and Saudi and who had a general practitioner specialty and degree.Conclusions: It could be concluded that a gap was detected in the knowledge and practices of primary health care physicians regarding pre-travel counselling for people with type 2 diabetes. Therefore, it is necessary to create easily accessible travel medicine education programmes for Saudi PHC providers to improve the management of travellers with diabetes.Trial registrationNot applicable

Background: Gastrointestinal (GI) symptoms are commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome (CHS). Case presentation: In this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS. Conclusion: In conclusion, this case demonstrates that a presumptive and incorrect diagnosis can mislead physicians, especially when dealing with challenging diagnoses. Therefore, patients with type 1 diabetes with unusual presentations, such as unexpectedly high pH and bicarbonate levels, with hyperglycemic ketosis should be screened for illicit drug use, especially cannabis.