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GLP-1 RA Escalation — RACP Adult Medicine MCQ

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HardEndocrinology & DiabetesGLP-1 RA EscalationRACP Adult Medicine

A 45-year-old taking empagliflozin is admitted for emergency abdominal surgery. Glucose is 8.2 mmol/L, bicarbonate 16 mmol/L and blood ketones 4.1 mmol/L. What is the most likely metabolic complication?

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Correct answer: C — SGLT2-inhibitor-associated euglycaemic diabetic ketoacidosis

The best answer is “SGLT2-inhibitor-associated euglycaemic diabetic ketoacidosis”. SGLT2 inhibition can produce ketoacidosis with only modest glucose elevation, especially during fasting, surgery or acute illness. The low bicarbonate and high ketones make this more than uncomplicated starvation ketosis. Management requires stopping the SGLT2 inhibitor, insulin with glucose, fluids and electrolyte monitoring; the glucose concentration must not falsely reassure clinicians.

Reference: Australian Diabetes Society: Australian type 2 diabetes glycaemic management algorithm: https://www.diabetessociety.com.au/guideline/australian-t2d-glycaemic-management-algorithm-june-2024/ ANZCA: Perioperative medicine resources: https://www.anzca.edu.au/resources/professional-documents