Patients taking SGLT2 inhibitors can develop diabetic ketoacidosis with blood glucose below 250 mg/dL, sometimes near normal. Triggers include acute illness, reduced intake, surgery, alcohol and insulin dose reduction. A patient on an SGLT2 inhibitor who presents unwell with vomiting, abdominal pain or breathlessness needs blood ketones and a venous gas regardless of glucose. Treatment follows standard DKA protocols, but dextrose is usually needed early alongside insulin because glucose is not high.
- Ask every unwell patient with diabetes whether they take an SGLT2 inhibitor.
- Check blood ketones and a venous gas even when glucose is normal.
- Start dextrose with insulin early, as glucose is often not raised.
- Stop the SGLT2 inhibitor during acute illness and document when to restart.
Why it matters
A normal glucose reading is the commonest reason this diagnosis is missed.
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