Presentation
A 52-year-old White British male presented to the emergency department after waking up feeling unwell following an isolated episode of binge drinking over a long weekend. He had taken his usual 2 g dose of metformin that morning after measuring a capillary blood glucose of 6.5 mmol/L.A few hours later, he developed acute abdominal discomfort, nausea, and vomiting. He was brought to the hospital via ambulance after a 111 call due to worsening symptoms.

Examination
On arrival, he was hypotensive with a systolic blood pressure of 65 mmHg, tachypneic (respiratory rate of 28 breaths per minute), but fully alert with a Glasgow Coma Scale of 15/15.The oxygen saturation was 97% and body temperature was 36.6°C.Electrocardiography showed tall T waves. The serum potassium was elevated at 6.7 mmol/L. The additional blood tests were also done, which confirmed diabetic ketoacidosis (DKA), along with raised serum amylase.

Diagnosis
The patient was diagnosed with DKA and suspected alcohol-related ketoacidosis (AKA).Pancreatitis was suspected given the elevated amylase, which later normalized. His medical records showed preserved C-peptide levels (1801 pmol/L), indicating intact endogenous insulin production, consistent with type 2 diabetes.

Management
He was immediately shifted to the ICU and managed. The management included fixed-rate intravenous insulin infusion and 0.9% sodium chloride fluid resuscitation. He also required vasopressor support for hypotension. The patient was stabilized and was shifted to the general ward. Metformin was discontinued due to concerns about its safety in the context of repeated renal impairment. He was discharged on a new insulin regimen (Abasaglar 6 units at bedtime) and scheduled for outpatient follow-up in the diabetes clinic.

Follow-Up
The patients underwent further investigations related to metabolic profile were performed to explore the underlying causes of his recurrent metabolic decompensation. The patients admitted to regular alcohol consumption of 14–18 units of vodka per week, often escalating to 20 units or more during binge episodes, particularly the night before each hospital admission.