Euglycaemic diabetic ketoacidosis is an established risk with SGLT2 inhibitors. Because these drugs lower glucose through the urine, a patient can be significantly acidotic with a blood glucose under 14 mmol/L (250 mg/dL), and the normal-looking glucose delays the diagnosis.
The usual triggers are reduced food intake, vomiting, acute illness, surgery, heavy alcohol use and sharp insulin dose reductions. When an SGLT2-treated patient presents with nausea, abdominal pain, breathlessness or malaise, measure blood ketones and a venous gas whatever the glucose.
- Measure blood ketones in any unwell patient on an SGLT2 inhibitor, whatever the glucose.
- Pause the SGLT2 inhibitor during acute illness with poor intake, and before major surgery as per local protocol.
- Give every new SGLT2 prescription with sick-day advice on when to stop and when to restart.
- Restart only once the patient is eating and drinking normally.
Why it matters
A normal glucose is exactly what lets euglycaemic ketoacidosis go unrecognised.
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