Management of Diabetic Ketoacidosis in Patients on SGLT2 Inhibitors
Introduction to SGLT2 Inhibitor Discontinuation
- The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend withholding SGLT2 inhibitors during critical medical illness when patients are at greater risk for ketosis 1, 2
Alternative Medication Selection
- For patients requiring cardio-renal protection, the American Diabetes Association recommends first-line alternative: GLP-1 receptor agonists with proven cardiovascular benefits (dulaglutide, liraglutide, semaglutide) 2, 3
- For patients with heart failure or CKD, consider nonsteroidal mineralocorticoid receptor antagonists if eGFR ≥25 mL/min/1.73 m² and normal potassium 1, 4
Glycemic Control and Insulin Therapy
Discharge and Follow-up
- Ensure complete DKA resolution before discharge: glucose <200 mg/dL, bicarbonate ≥18 mEq/L, pH >7.3, anion gap ≤12 mEq/L 5, 6
- Transition to subcutaneous insulin 2-4 hours before stopping IV insulin to prevent rebound ketoacidosis 5, 7
- Monitor for persistent ketonuria/glucosuria which may persist 8-11 days after last SGLT2 inhibitor dose
- Follow-up requirements include endocrinology follow-up to optimize insulin regimen and assess glycemic control within 1 week 7
- Ongoing monitoring includes HbA1c every 3 months, annual kidney function assessment 1, 3