SGLT2 inhibitors keep glucose low by excreting it in the urine, so a patient can develop ketoacidosis with a glucose only mildly raised or even normal. This euglycaemic presentation is easily missed in a vomiting, dehydrated or post-operative patient whose glucose looks reassuring.
Triggers include acute illness, reduced intake, surgery, alcohol and insulin dose reductions. Check blood ketones and a venous gas in any unwell patient taking an SGLT2 inhibitor, stop the drug, and treat ketoacidosis with fluids and insulin with glucose, because the glucose will not be high enough to give insulin alone.
- Ask about SGLT2 inhibitor use in every unwell patient with diabetes.
- Check blood ketones and a venous gas even if glucose is normal.
- Stop the SGLT2 inhibitor during acute illness.
- Treat ketoacidosis with insulin plus glucose-containing fluids when glucose is not high.
- Do not restart until the patient is eating and drinking normally.
Why it matters
A normal glucose falsely reassures, and these patients are often sent home or treated for gastroenteritis.
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