Patients on SGLT2 inhibitors are vulnerable to euglycaemic diabetic ketoacidosis during acute illness, dehydration or the fasting around surgery, and it is missed because the glucose looks reassuring.
The practical rule is to pause the drug when a patient cannot keep up oral intake, is vomiting, or is dehydrated, and to stop it before planned surgery following local perioperative timing. In any unwell patient on an SGLT2 inhibitor, check ketones even when the glucose is near-normal, because ketoacidosis can develop with glucose well below the usual threshold.
Restart only once the patient is eating, drinking and clinically well. This is established practice, reinforced by the higher rate of volume-depletion events seen with these drugs.
- Hold SGLT2 inhibitors during acute illness with poor oral intake, vomiting or dehydration.
- Stop them before planned surgery, following local perioperative guidance on timing.
- In an unwell patient on an SGLT2 inhibitor, check blood or urine ketones even if glucose is near-normal.
- Euglycaemic diabetic ketoacidosis can occur with glucose below 14 mmol/L (250 mg/dL).
- Restart only once the patient is eating, drinking and clinically well.
Why it matters
Euglycaemic ketoacidosis is missed precisely because the glucose looks reassuring.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for diabetes & endocrinology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free