Empagliflozin and Risk of Diabetic Ketoacidosis in Type 2 Diabetes

Risk Factors and Prevention Strategies

The American Diabetes Association recommends that empagliflozin be used with caution in patients with type 2 diabetes, particularly during periods of metabolic stress such as illness, surgery, or reduced food intake, due to the risk of euglycemic diabetic ketoacidosis (euDKA) 1
Insulin deficiency is a rare but possible predisposing risk factor for DKA in patients with type 2 diabetes taking empagliflozin 1
Reduced caloric intake due to illness or fasting is a predisposing risk factor for DKA in patients taking empagliflozin, according to the American College of Physicians 1, 2
Acute illness or infection is a predisposing risk factor for DKA in patients taking empagliflozin, as reported by the Mayo Clinic 2
Surgical procedures are a predisposing risk factor for DKA in patients taking empagliflozin, and the American College of Surgeons recommends discontinuing empagliflozin 3-4 days before scheduled surgery 1, 2
Alcohol consumption is a predisposing risk factor for DKA in patients taking empagliflozin, according to the National Institute on Alcohol Abuse and Alcoholism 2
Volume depletion is a predisposing risk factor for DKA in patients taking empagliflozin, as reported by the American Heart Association 2

Patients with reduced renal function are at higher risk of DKA when taking empagliflozin, according to the American College of Cardiology 3, 2
Elderly patients are at higher risk of DKA when taking empagliflozin, as reported by the American Geriatrics Society 3, 4
Patients on diuretics are at higher risk of DKA when taking empagliflozin, according to the American College of Cardiology 3, 4
Patients with low systolic blood pressure are at higher risk of DKA when taking empagliflozin, as reported by the American Heart Association 3, 4

Empagliflozin offers significant cardiovascular and renal benefits for patients with type 2 diabetes, according to the European Society of Cardiology 5, 6

The American Diabetes Association recommends discontinuing empagliflozin 3-4 days before scheduled surgery to prevent life-threatening diabetic ketoacidosis (DKA), which can occur even with normal blood glucose levels 7

In patients taking empagliflozin, the American Society of Anesthesiologists suggests establishing glucose infusion if the patient remains fasting during emergency procedures, to prevent ketoacidosis 8
The European Society of Anaesthesiology recommends monitoring closely for ketoacidosis with blood or urine ketone testing in patients who have discontinued empagliflozin before emergency surgery 9

In patients slated for CAR T‑cell infusion, empagliflozin should be stopped ≥ 3 days (72 hours) before the scheduled procedure to align with surgical peri‑operative recommendations and mitigate the risk of diabetic ketoacidosis; this timing recommendation is endorsed by the 2025 Circulation guideline 10.