Summary of a 2018 Australian Case Series by Meyer et al. (28)

Number of cases13
Hospital courseNine intensive care unit admissions
TreatmentAll IV insulin
SGLT2 inhibitorDapagliflozin nine cases; empagliflozin four cases
Diagnosis issuesDKA diagnosis overlooked in two patients, unawareness of the association of SGLT2 inhibitors and DKA in six patients
TriggersMissed insulin in five cases, undiagnosed type 1 diabetes in two cases, infection in five cases, surgery in three cases, decreased carbohydrate intake in five cases
ConclusionMost patients did not recognize DKA. Treating physicians did not initially recognize the DKA in many cases due to euglycemia. Treatment was delayed. Most cases were severe and had identifiable triggers.
Recommendations• Temporary cessation of SGLT2 inhibitors during acute illness and surgery
• Caution early on regarding euglycemia associated with DKA
• Holding the SGLT2 inhibitor for a period of time after resolution of illness and post-surgery
• Ensuring adequate hydration and insulin administration
• Delivering an appropriate amount of carbohydrate to avoid ketosis