SGLT2 inhibitors can cause ketoacidosis with near-normal glucose, so a normal meter reading does not exclude it. The established advice is to pause the drug during acute illness with vomiting, diarrhoea, poor oral intake or dehydration, and before major surgery, restarting once eating and drinking normally.
A patient who feels unwell with nausea, abdominal pain or breathlessness while on one needs a ketone check, blood or urine, whatever the glucose. Insulin should not be stopped in someone who uses it, even when not eating.
- Pause SGLT2 inhibitors during vomiting, diarrhoea, poor intake or dehydration.
- Check ketones in any unwell patient on an SGLT2 inhibitor, even with normal glucose.
- Stop before planned major surgery, following local perioperative guidance.
- Never advise stopping basal insulin during illness.
Why it matters
Euglycaemic ketoacidosis is missed precisely because the glucose looks reassuring.
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