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Warning: SGLT-2s Can Cause DKA at Near-Normal Glucose Levels

By Miriam E. Tucker , ,

SGLT-2 inhibitors (SGLT-2s), a class of diabetes medications that includes canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), and an empagliflozin/linagliptin combo (Glyxambi) may cause something known as euglycemic diabetic ketoacidosis (eDKA). This serious condition is defined as DKA with normal or near-normal blood glucose levels.

In DKA, harmful levels of ketones (a type of blood acid) build up in the body. DKA is usually associated with blood glucose levels above 250 mg/dl, lack of or too little insulin, and dehydration, and is a medical emergency requiring immediate hospitalization. The problem with SGLT-2s is that, because they cause loss of excess blood glucose in the urine, blood glucose levels can be normal even when full-blown DKA is present. What’s more, this type of DKA can go unrecognized because patients and health care providers usually check for DKA (with blood and/or urine tests for ketones) only when blood glucose is very high. A June 2015 article in Diabetes Care reported eDKA in two people with type 2 and seven people with type 1 who were using SGLT-2s. All required emergency treatment for eDKA, and fortunately all made complete recoveries.

If you take an SGLT-2 inhibitor, discuss the risk of eDKA with your health care provider and create a plan for avoiding it. You may be at risk for eDKA if you take an SLGT-2 and have an acute illness or other stress to the body such as surgery. But eDKA can occur in the absence of any known risk factors, too. SGLT-2s are not approved for use in type 1, and because people with type 1 diabetes are at a much higher risk of DKA in general, experts typically recommend people with type 1 avoid taking SGLT-2s. Most important, if you feel nauseated or are vomiting, or if you become short of breath or extremely fatigued (all signs of DKA), test your urine ketones even if your blood glucose is normal, and contact your health care provider immediately if your urine tests positive for ketones.
Source: Diabetes Care, published online June 15, 2015