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SGLT2 inhibitor-associated euglycaemic diabetic ketoacidosis — MSRA MCQ

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Hardall topics relevant for this examSGLT2 inhibitor-associated euglycaemic diabetic ketoacidosisMSRA

A 56-year-old woman with type 2 diabetes mellitus contacts her GP practice during an acute appointment. Her usual treatment is metformin, empagliflozin 10 mg once daily and insulin degludec 28 units nightly. She has continued her basal insulin. She has had 24 hours of vomiting and poor oral intake associated with presumed viral gastroenteritis. She reports increasing nausea, diffuse abdominal pain, thirst and unusual fatigue. She is alert and orientated. Her temperature is 37.4°C, blood pressure 108/66 mmHg, pulse 96 beats/minute and respiratory rate 22 breaths/minute. Capillary glucose is 10.2 mmol/L. Point-of-care blood ketones are 3.4 mmol/L; venous blood gas shows pH 7.28 and bicarbonate 14 mmol/L. What is the most appropriate management now?

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

Reveal the answer and explanation

Correct answer: C — Withhold empagliflozin and arrange immediate emergency transfer to hospital for diabetic ketoacidosis management

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

This patient has diabetic ketoacidosis (DKA): she has established diabetes, blood ketones above 3.0 mmol/L and metabolic acidosis (pH below 7.3 with bicarbonate below 15 mmol/L). The relatively modest glucose concentration does not exclude DKA. SGLT2 inhibitors can cause an atypical, near-euglycaemic presentation, particularly during restricted intake, vomiting or dehydration. Empagliflozin must therefore be stopped and she requires immediate hospital transfer for protocol-led intravenous fluid, insulin and electrolyte management. ([medicines.org.uk](https://www.medicines.org.uk/emc/medicine/28973?utm_source=openai)) A is appropriate only for uncomplicated intercurrent illness without significant ketonaemia or acidosis. B underestimates a biochemical diabetic emergency; same-day specialist review is insufficient. C may appear attractive because insulin is required to clear ketones, but outpatient correction insulin and repeat testing are unsafe when DKA is already established and intravenous treatment with close potassium monitoring is required. E addresses future prescribing but delays emergency treatment; whether empagliflozin can ever be restarted should be decided after recovery and assessment of the precipitant.

Reference: Empagliflozin 10 mg and 25 mg film-coated tablets (previously known as Jardiance) - Summary of Product Characteristics (SmPC) (May 2026) — https://www.medicines.org.uk/emc/medicine/28973 SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness (18 March 2020) — https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness?fromsource=MAS JBDS: Diabetes at the Front Door Guideline (May 2023) — https://www.rightdecisions.scot.nhs.uk/m/0qggrpea/jbds_16_diabetes_at_the_front_door_guideline_with_qr_code_may_2023.pdf