Starting SGLT2 inhibitors earlier means more patients are on them during intercurrent illness, surgery and fasting — the settings where euglycaemic diabetic ketoacidosis occurs. The glucose can look reassuringly normal while ketones climb, so the diagnosis is missed if you anchor on the meter.
The counselling is established and belongs at the first prescription, not only at review: pause the drug during acute illness, dehydration, very low carbohydrate intake or before planned surgery, and check ketones rather than glucose when the patient is unwell. Restart once they are eating, drinking and well.
- Hold the SGLT2 inhibitor during acute illness, vomiting, dehydration or fasting, and before planned surgery.
- When a patient on an SGLT2 inhibitor is unwell, check ketones — glucose can be near-normal in euglycaemic ketoacidosis.
- Give sick-day advice at the first prescription, not only at review.
- Restart the drug once the patient is eating, drinking and well.
Why it matters
As these drugs move first-line from diagnosis, more patients carry a ketoacidosis risk a glucose meter will not show.
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