SGLT2 inhibitors can cause ketoacidosis with near-normal blood glucose, because the drug keeps lowering glucose through the urine while ketones accumulate. A normal fingerstick reading does not rule it out.
In any patient on an SGLT2 inhibitor who presents with nausea, vomiting, abdominal pain, breathlessness or malaise — especially after reduced food intake, surgery, an acute illness or a cut in insulin — check blood ketones and a venous gas. Withhold the drug during acute illness and before major surgery, and restart once the patient is eating and drinking normally.
- A normal glucose does not exclude ketoacidosis on an SGLT2 inhibitor
- Check blood ketones and a venous gas when an SGLT2 user is unwell with vomiting or abdominal pain
- Withhold the drug during acute illness, poor intake or before major surgery
- Restart only once the patient is eating and drinking normally
Why it matters
Euglycaemic ketoacidosis is missed precisely because the glucose reassures.
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