Patients taking SGLT2 inhibitors can develop diabetic ketoacidosis with glucose below the usual threshold, sometimes near normal. The usual triggers are acute illness, reduced intake, surgery, alcohol or a cut in insulin dose.
The danger is that a normal glucose makes ketoacidosis easy to dismiss. In any unwell patient on an SGLT2 inhibitor with vomiting, abdominal pain, breathlessness or malaise, check blood ketones and a venous gas whatever the glucose. Treatment needs insulin with dextrose to clear ketones while keeping glucose up.
- Ask every unwell patient with diabetes whether they take an SGLT2 inhibitor
- Check blood ketones and a venous gas regardless of the glucose level
- Treat with fixed-rate insulin plus dextrose, not by glucose alone
- Stop the SGLT2 inhibitor during acute illness and advise sick-day rules at discharge
Why it matters
A normal glucose is the reason this ketoacidosis gets missed.
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