Euglycaemic diabetic ketoacidosis presents with nausea, vomiting, abdominal pain, breathlessness or malaise while capillary glucose is normal or only mildly raised, often below 14 mmol/L (250 mg/dL). It is easy to miss because the glucose reading reassures.
It is more likely during intercurrent illness, reduced food intake, fasting (including religious fasts), surgery, alcohol excess, a big cut in insulin dose, and in type 1 diabetes or insulin-deficient type 2 diabetes.
In any unwell patient taking an SGLT2 inhibitor, measure blood ketones and venous gas regardless of glucose, and pause the drug during acute illness.
- Normal glucose does not exclude DKA in a patient on an SGLT2 inhibitor.
- Measure blood ketones and a venous blood gas in any such patient who is vomiting, breathless or has abdominal pain.
- Advise patients to stop the SGLT2 inhibitor on sick days, at least 3 days before planned surgery (4 for ertugliflozin) and during prolonged fasting, and to restart when eating normally.
- Do not cut insulin sharply in a patient starting an SGLT2 inhibitor.
Why it matters
Sick-day counselling shouldn't disappear after the first prescription.
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