SGLT2 inhibitors can cause ketoacidosis with near-normal blood glucose, most often during acute illness, reduced intake, fasting or around surgery. Because glucose may not be high, neither patient nor emergency team may suspect it.
The established advice is to pause the drug while a patient is unwell with poor oral intake, vomiting or dehydration, and to restart once eating and drinking normally. Before planned surgery the drug is usually stopped a few days ahead. A patient who is unwell on an SGLT2 inhibitor should have ketones checked whatever the glucose reading.
- Tell every patient starting an SGLT2 inhibitor to pause it during vomiting, diarrhoea or a day of poor intake.
- Repeat the sick-day advice at review visits, not only at the first prescription.
- Check blood ketones in any unwell patient on an SGLT2 inhibitor, even if glucose is normal.
- Plan to withhold the drug before elective surgery and note when it can restart.
Why it matters
Euglycaemic ketoacidosis is missed precisely because the glucose looks reassuring.
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