The Australian Diabetes Society has issued an alert on the risks of diabetic ketoacidosis (DKA) in people taking SGLT2 inhibitors during the peri-operative period.

The alert follows reports of patients with type 2 diabetes developing severe acidosis with the drugs during the peri-operative period, particular if they had been fasting or were dehydrated. Unusually, DKA occurred with near normal or only mildly elevated blood glucose levels and was only detected by blood ketone testing.

The Society therefore recommends DKA be considered in patients taking drugs such as dapagliflozin and empagliflozin, noting that severe ketosis may exist even where BGL is <16 mmol/L.

It provides several practice points for patients taking SGLT2 inhibitors, inlcuding:

1. Stop the drugs at least 3 days pre-operatively
2. If SGLT2 inhibitors have not been stopped, postpone non-urgent surgery in patients at high risk of DKA (blood ketones >0.6 mmol/L, or HbA1c >9.0%).
3. Routinely check blood glucose and ketone levels in the perioperative period if the patient is unwell or fasting or has limited oral intake.
4. Perform urgent VBG to measure the pH if blood ketone level is >0.6 mmol/L in an unwell pre- or peri-operative patient or >1.5 mmol/L in all other unwell inpatients.
5. Only restart SGLT2 inhibitor when the patient is eating and drinking and close to discharge.
6. For day surgery/procedures, only re-start SGLT2 inhibitor if the patient is on full oral intake. (and perhaps delay a further 24 hours).
7. Check blood glucose and ketone levels if patient is unwell in the week following surgery.

Full advice is available here.