Ketoacidosis in people taking an SGLT2 inhibitor can occur with only modestly raised glucose, so a normal reading does not exclude it. Tell patients to pause the tablet during vomiting, diarrhoea, poor oral intake or fasting before a procedure, and to restart it once eating and drinking normally.
Any patient who is unwell with abdominal pain, nausea, fast breathing or marked fatigue should have blood ketones or an acid-base check, whatever the glucose says. Write the rule on the prescription or the discharge note, because it is easily forgotten after the first visit.
- Pause the SGLT2 inhibitor when vomiting, not eating or drinking, or before planned fasting
- Euglycaemic ketoacidosis can show near-normal glucose, so check ketones when unwell
- Restart once eating and drinking are back to normal
- Repeat the advice at follow-up visits, not only when starting the drug
- Offer the same advice to patients also taking metformin and an ACE inhibitor or diuretic
Why it matters
A normal glucose can reassure the clinician at the wrong moment.
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