SGLT2 inhibitors can cause ketoacidosis with near-normal glucose, most often during acute illness, vomiting, reduced food intake, surgery or heavy alcohol use. Because glucose may be only modestly raised, the diagnosis is easily missed in an emergency department.
Standard advice is to pause the drug during acute illness with poor oral intake and before planned surgery, to restart once eating and drinking normally, and to check ketones if unwell. Patients often hear this at the first prescription and forget it a year later.
- Pause the SGLT2 inhibitor during vomiting, diarrhoea or poor oral intake, and restart once eating normally.
- Stop it before planned surgery or procedures needing fasting, per local perioperative guidance.
- Check ketones in an unwell patient on an SGLT2 inhibitor even when glucose is near normal.
- Repeat the sick-day advice at review visits, not only at the first prescription.
Why it matters
Normal-glucose ketoacidosis is missed because the glucose reading reassures.
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