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SGLT2 inhibitor–associated diabetic ketoacidosis with near-normal glucose — MRCEM SBA MCQ

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HardResuscitation and critical illnessSGLT2 inhibitor–associated diabetic ketoacidosis with near-normal glucoseMRCEM SBA

A 54-year-old woman with type 2 diabetes takes empagliflozin. After two days of vomiting and poor oral intake, she presents with abdominal pain and deep, rapid breathing. She is alert, with a blood pressure of 112/70 mmHg. After an initial litre of 0.9% sodium chloride, she has passed urine. Her capillary glucose is 10.3 mmol/L, blood ketones are 5.2 mmol/L, venous pH is 7.19, bicarbonate is 11 mmol/L and potassium is 4.2 mmol/L. Intravenous access and monitoring are established; she has not received insulin. Which is the most appropriate management plan now?

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

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Correct answer: A — Stop empagliflozin; give potassium-containing isotonic saline and 10% glucose alongside fixed-rate intravenous insulin; admit for monitored treatment.

Marked ketonaemia and metabolic acidosis establish diabetic ketoacidosis despite a glucose of 10.3 mmol/L. Empagliflozin and reduced food intake make an SGLT2 inhibitor–associated, near-normal-glucose presentation particularly likely. The drug should be stopped. Insulin is needed to suppress ketone production, while glucose must be infused from the outset at this glucose concentration so that intravenous insulin can continue safely. Having passed urine with a potassium of 4.2 mmol/L, she also requires potassium-containing replacement fluid and frequent biochemical reassessment during admission. ([gov.uk](https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis)) B correctly treats the ketosis with fixed-rate insulin but waits too long to provide glucose, risking hypoglycaemia before the acidosis resolves. C provides glucose but delays the treatment needed to clear ketones: a rise above 14 mmol/L is not a prerequisite for insulin. D is attractive because variable-rate insulin is used in other inpatient settings, but active ketoacidosis calls for a fixed-rate infusion; variable-rate insulin may become appropriate after ketoacidosis has resolved if the patient remains unable to eat. E similarly substitutes subcutaneous rapid-acting insulin before biochemical resolution and before she can reliably eat. None of her relatively modest glucose readings makes this suitable for treatment as uncomplicated hyperglycaemia. ([nnuh.nhs.uk](https://www.nnuh.nhs.uk/publication/download/flow-chart-for-diabetic-ketoacidosis-in-adults-management-of))

Reference: Guidelines for the Emergency Management of Diabetic Ketoacidosis (June 2024) — https://www.gloshospitals.nhs.uk/documents/4876/X459_06_24.pdf SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis (18 April 2016) — https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis The Management of Diabetic Ketoacidosis in Adults (Uploaded 26 June 2024) — https://www.nnuh.nhs.uk/publication/download/flow-chart-for-diabetic-ketoacidosis-in-adults-management-of