Older adults gain as much from SGLT2 inhibitors as anyone, but they also dehydrate faster and are more often on diuretics and renin-angiotensin blockers. The established approach is to pause the SGLT2 inhibitor during an acute illness with poor intake, vomiting or diarrhoea, and before major surgery or prolonged fasting, and to restart once eating and drinking normally.
Euglycaemic ketoacidosis can occur with near-normal glucose, so a sick patient on an SGLT2 inhibitor with nausea, abdominal pain or breathlessness needs ketones checked even if the glucose looks reassuring. Give the advice in writing, and repeat it at review rather than only at the first prescription.
- Pause the SGLT2 inhibitor during vomiting, diarrhoea or poor oral intake, and restart when eating normally.
- Check ketones in an unwell patient on an SGLT2 inhibitor even when glucose is near normal.
- Review diuretic doses when starting an SGLT2 inhibitor in a frail older adult.
- Give sick-day rules in writing and repeat them at each review.
Why it matters
The patients with the most to gain are also the ones most exposed to volume depletion and ketoacidosis.
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