New ADS advice on how to manage DKA with SGLT2 inhibitors

Several changes have been made and new information added to updated advice from the Australian Diabetes Society on the management of diabetic ketoacidosis (DKA) with SGLT2 inhibitor.

In an alert update, the ADS has issued new recommendations including:

  • Blood testing is now strongly recommended to be used in detecting and monitoring DKA as urine ketone testing may not be reliable under these circumstances (since SGLT2 inhibitors may also reduce urinary ketone excretion).
  • A stronger emphasis that DKA with SGLT2 inhibitors may occur with normal or only mildly elevated blood glucose levels (ie euglycaemic DKA).
  • DKA should be suspected in patients taking anSGLT2 inhibitor who have fingerprick capillary blood ketone levels of .1.0mmol/L in the periporeative period (previous advice was >0.6mmol/L) or >1.5mmol/L at any other time.
  • Have low pH <7.3 on VBG or <7.35 ABG, and low bicarbonate <15mmol/L with a high anion gap >12, indicating metabolic acidosis

The ADS statement now also includes three new ‘Recommendations for Practice’ in addition to previous advice on stopping an SGLT2 inhibitors in the perioperative period:

When clinicians are commencing patients on an SGLT2 inhibitor, the patient should be informed about the risk of DKA. Ideally written information including potential risk factors, warning symptoms and a management plan should be given to the patient.

  • Advise temporary cessation of SGLT2 inhibitor with significant intercurrent illness.
  • SGLT2 inhibitors do not require cessation, excepting on day of procedure, for minor operations with short period of fasting (4 hours), with no risk of dehydration and with rapid resumption of normal food and fluid intake following the procedure.

The new recommendations also include additional advice when stopping a SGLT2 inhibitor to be aware that if it is part of a fixed dose combination this will lead to withdrawal of two glucose lowering drugs.

It is also suggested that during the perioperative period hourly blood glucose and blood ketone testing is done during procedure and 2 hourly following procedure until eating and drinking normally

The alert update also includes more detailed advice on the exact course of action to take if blood ketone levels are above >1.0 mmol/L in an unwell pre- or peri-operative patient, or >1.5 mmol/L in all other unwell inpatients who have been on an SGLT2 inhibitor.

It recommends that the treating medical officer, or anaesthetist, should be contacted to perform an URGENT VBG to measure the pH.  If pH <7.3 on VBG and/or HCO3 <15  the treating medical officer should manage the patient with rehydration as well as intravenous insulin-dextrose infusion. Blood glucose, ketones and VBG should be monitored hourly and if blood ketones do not begin to fall and pH is not restored, the insulin, and therefore dextrose infusion rate will need to be increased.

And if the SGLT2 inhibitor has not been ceased prior to non-urgent surgery, four different courses of action are recommended based on HbA1c, blood ketone and pH levels.

The update also states that DKA recommendations apply to newer SGLT2 inhibitor products such as ertugliflozin (Steglatro) and new combinations swith metformin (Segluromet) or with DPP4 inhibitors ( Glyxambi, Qtern, Steglujan).

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