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Suspected SGLT2 inhibitor-associated diabetic ketoacidosis — MSRA MCQ

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ModerateNephrologySuspected SGLT2 inhibitor-associated diabetic ketoacidosisMSRA

A 59-year-old man with type 2 diabetes and CKD G3b attends an urgent GP appointment. His regular medicines include dapagliflozin 10 mg once daily, insulin glargine and insulin aspart. Since yesterday he has had vomiting, abdominal pain, marked fatigue and poor oral intake after a presumed viral gastroenteritis. He has continued all medication, including insulin. He is afebrile, BP 118/70 mmHg, pulse 102 bpm and respiratory rate 22 breaths/min. Capillary blood glucose is 10.8 mmol/L. There is no focal abdominal tenderness. Urine dipstick shows glucose 4+ and ketones 2+. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Stop dapagliflozin immediately and arrange urgent assessment for diabetic ketoacidosis with blood ketone measurement

Explanation lettering: B = shown as A · D = shown as B · A = shown as D

This presentation is concerning for SGLT2 inhibitor-associated diabetic ketoacidosis (DKA), which may occur with only modest hyperglycaemia. The discriminating features are dapagliflozin exposure, acute reduced intake and vomiting, abdominal pain, tachypnoea, fatigue and ketonuria despite a capillary glucose of 10.8 mmol/L. Dapagliflozin should be stopped immediately, and he needs urgent assessment for DKA with blood ketones, which are preferred to urine ketones. A is inappropriate because symptoms and ketonuria require immediate assessment rather than deferred community monitoring. C correctly stops dapagliflozin but incorrectly advises withholding insulin; intercurrent illness increases insulin requirements and insulin omission can worsen ketosis. D may appear reasonable for hyperglycaemia, but the glucose concentration does not exclude DKA and insulin correction must not delay urgent metabolic assessment. E underestimates the significance of the symptom cluster and ketonuria in an SGLT2 inhibitor user. Dapagliflozin can be restarted only once ketones are normal and the patient is clinically stable.

Reference: Forxiga 10 mg film-coated tablets - Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/7607/smpc