SGLT2 Inhibitors and Euglycemic Diabetic Ketoacidosis Risk Management

Mechanism and Risk Factors

• SGLT2 inhibitors like dapagliflozin can cause volume depletion, increasing stress hormones, and when combined with acute illness or insulin dose reduction, significantly increases the risk of euglycemic diabetic ketoacidosis. 1

Clinical Guidelines

• The American Diabetes Association and KDIGO consensus report emphasizes the importance of monitoring for ketosis in patients taking SGLT2 inhibitors. 1

• SGLT2 inhibitor medications should be withheld for at least 3 days prior to major surgery or procedures requiring prolonged fasting. 2

Management Approaches

• For patients with ketonuria, clinicians should address the underlying cause of ketosis before considering an SGLT2 inhibitor. 1

• Alternative glucose-lowering agents that don't increase ketone production should be used in patients at risk for ketoacidosis. 3

Monitoring Recommendations

• If an SGLT2 inhibitor is eventually considered (after resolution of ketonuria), implement strict monitoring protocols including blood or urine ketone testing and patient education on signs/symptoms of ketoacidosis. 1

• Sick day protocols should include instructions to hold SGLT2 inhibitor medication during illness. 4