SGLT2 inhibitors such as dapagliflozin and empagliflozin can cause diabetic ketoacidosis with blood glucose below 14 mmol/L (250 mg/dL), and sometimes near normal. Because glucose is not high, the diagnosis is easily missed.
Suspect it in any patient on an SGLT2 inhibitor who is unwell with nausea, vomiting, abdominal pain, breathlessness or malaise, especially after surgery, fasting, acute illness, reduced insulin doses or heavy alcohol intake. Check blood ketones and a venous gas regardless of glucose.
Treatment follows usual ketoacidosis principles, but dextrose is needed early alongside insulin because glucose is not high. Stop the SGLT2 inhibitor and do not restart until the patient is well and eating.
- Check ketones and a venous gas in any unwell patient on an SGLT2 inhibitor, whatever the glucose
- Give dextrose with the insulin infusion when glucose is near normal
- Stop the SGLT2 inhibitor during acute illness and before major surgery
- Ask about recent fasting, surgery and alcohol
Why it matters
A normal glucose does not exclude ketoacidosis in these patients.
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