SGLT2 inhibitors lower glucose by urinary loss, so diabetic ketoacidosis in a patient taking one can present with a near-normal blood glucose. A reassuring finger-prick reading in someone who is vomiting, not eating, dehydrated or post-operative does not exclude it.
Check a capillary or serum ketone and a venous gas with bicarbonate and anion gap. Pause the SGLT2 inhibitor during acute illness, fasting or major surgery, and restart once the patient is eating and drinking normally.
- Measure blood ketones in any unwell patient on an SGLT2 inhibitor, whatever the glucose reading.
- Add a venous gas with bicarbonate and anion gap when ketones are raised.
- Pause the SGLT2 inhibitor during acute illness, prolonged fasting or major surgery.
- Give sick-day advice at every review, not only at the first prescription.
Why it matters
Euglycaemic ketoacidosis is missed precisely because the glucose reading is reassuring.
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