Normal Blood Sugar, But Still in DKA? The Hidden Danger of Euglycemic Ketoacidosis

Euglycemic diabetic ketoacidosis can challenge one of the most familiar clinical shortcuts in diabetes care: DKA should come with markedly elevated glucose. In patients taking sodium-glucose cotransporter 2 (SGLT2) inhibitors, however, dangerous ketoacidosis may develop while glucose remains normal or only modestly elevated. As a result, euglycemic DKA in patients taking SGLT2 inhibitors can be missed when clinicians rely too heavily on glucose as a screening signal. Recognizing the pattern, particularly during illness, fasting, or surgery, can prevent a potentially life-threatening delay in treatment.

Table of Contents

• Why SGLT2 inhibitors can mask the usual DKA warning sign
• How to recognize and triage euglycemic DKA
• When to stop SGLT2 inhibitors before procedures
• Sick-day rules clinicians should teach patients
• Conclusion
• Frequently asked questions

Why Euglycemic DKA With SGLT2 Inhibitors Can Be Missed

SGLT2 inhibitors have changed diabetes, heart failure, and chronic kidney disease management. Drugs such as empagliflozin (Jardiance), dapagliflozin (Farxiga), and canagliflozin (Invokana) promote urinary glucose excretion and can provide important cardiorenal benefits. However, that same glucose-lowering mechanism can make ketoacidosis harder to recognize.

Normally, marked hyperglycemia acts like a clinical alarm for DKA. With an SGLT2 inhibitor on board, glucose can continue leaving the body through the urine. Therefore, a patient may develop significant ketonemia and metabolic acidosis without the glucose elevation clinicians traditionally expect.

The 2026 ADA Standards of Care note that up to one-third of people taking SGLT2 inhibitors who develop DKA may present with glucose below 200 mg/dL. Although DKA remains uncommon among people with type 2 diabetes using these agents, the unusual presentation makes awareness essential.

Several factors can increase risk. These include prolonged fasting, dehydration, acute illness, surgery, very-low-carbohydrate eating patterns, excessive alcohol intake, and relative insulin deficiency. Consequently, a reassuring glucose value should never outweigh a concerning clinical picture.

Diabetes in Control has previously covered the association between SGLT2 inhibitors and ketoacidosis. Current guidance strengthens the practical message: clinicians need to think beyond glucose when an at-risk patient becomes ill.

Recognizing and Triaging Suspected Euglycemic DKA

The key clinical rule is simple: normal glucose does not rule out DKA.

Patients with euglycemic DKA may report nausea, vomiting, abdominal pain, weakness, poor appetite, excessive thirst, or shortness of breath. In more advanced cases, tachypnea, dehydration, altered mental status, or Kussmaul-type breathing may develop. Because these symptoms overlap with infection, gastrointestinal illness, and postoperative complications, medication history matters.

Therefore, clinicians should specifically ask whether the patient takes an SGLT2 inhibitor. A medication list showing Jardiance, Farxiga, Invokana, or another agent in the class should lower the threshold for evaluating ketones and acid-base status.

The 2024 international consensus report on hyperglycemic crises defines DKA using diabetes or hyperglycemia, elevated ketones, and metabolic acidosis. Importantly, a history of diabetes can satisfy the glucose component even when current glucose is not elevated. Blood beta-hydroxybutyrate measurement is preferred for assessing ketonemia.

If SGLT2 inhibitor-associated euglycemic DKA is suspected, clinicians should evaluate the patient urgently rather than waiting for glucose to rise. Assessment generally includes electrolytes, bicarbonate, venous blood gas or pH, beta-hydroxybutyrate, renal function, and calculation of the anion gap.

Once DKA is identified, the SGLT2 inhibitor should be stopped and standard DKA management initiated. Treatment typically requires fluids, insulin, electrolyte monitoring, and often earlier dextrose because glucose may already be near the normal range. In addition, clinicians should identify and treat the precipitating illness or stressor.

SGLT2 Inhibitors Before Surgery and Procedures

The perioperative period deserves special attention because fasting, surgical stress, reduced insulin exposure, and dehydration can converge quickly.

According to the ADA’s 2026 hospital care standards, SGLT2 inhibitors should be held for three to four days before elective surgery. Specifically, most agents should be stopped three days before a scheduled procedure, while ertugliflozin should be stopped four days beforehand.

This recommendation matters even when preoperative glucose looks excellent. In fact, glucose alone cannot confirm that the metabolic effects associated with SGLT2 inhibition have disappeared.

For urgent or nonelective surgery, clinicians may not have the luxury of a multiday medication hold. Therefore, postoperative teams should maintain a higher index of suspicion for euglycemic DKA, particularly when unexplained nausea, tachypnea, acidosis, or clinical deterioration develops.

Restarting therapy also requires judgment. Generally, the precipitating risk factors should have resolved and the patient should be clinically stable with adequate nutritional intake. Simply completing the procedure does not automatically mean the medication should restart.

Clear communication between primary care, endocrinology, surgery, anesthesia, and inpatient teams can prevent gaps. Moreover, patients need written instructions because medication names and stopping intervals can easily become confusing.

Sick-Day Rules Every At-Risk Patient Should Know

Preventing SGLT2 inhibitor-associated euglycemic DKA begins long before an emergency department visit. Every patient prescribed an SGLT2 inhibitor should understand what to do during acute illness.

Patients should know that vomiting, diarrhea, fever, dehydration, or an inability to eat and drink normally can change the safety of their medication plan. During significant acute illness or prolonged fasting, SGLT2 inhibitors generally need to be temporarily withheld according to the patient’s clinician-directed sick-day plan.

However, patients who also use insulin should not independently stop insulin simply because they are eating less. Insulin deficiency is a major driver of ketone production, so inappropriate insulin omission may substantially increase DKA risk.

Clinicians should also explain that checking glucose alone is not enough. When symptoms suggest ketoacidosis, ketone testing may be necessary even if a continuous glucose monitor or finger-stick reading appears reassuring.

Patients need clear instructions about when to seek urgent medical care. Persistent vomiting, abdominal pain, difficulty breathing, marked weakness, confusion, dehydration, or elevated ketones should prompt immediate assessment. If symptoms are concerning, patients should not delay care because their glucose is “normal.”

Finally, education should be repeated rather than treated as a one-time counseling point. A short discussion when the drug is prescribed, reinforced before procedures and during follow-up visits, can turn an uncommon adverse event into a recognizable and actionable risk.

Conclusion

SGLT2 inhibitors provide substantial benefits for many patients, but their ability to lower glucose through urinary excretion changes the traditional presentation of DKA. Consequently, euglycemic DKA associated with SGLT2 inhibitor use should remain on the differential whenever a patient develops unexplained nausea, vomiting, abdominal pain, tachypnea, ketonemia, or metabolic acidosis.

The practical message is straightforward. Do not use a normal glucose level to exclude DKA. Hold SGLT2 inhibitors appropriately before elective surgery, recognize high-risk periods such as illness and fasting, and give every patient clear sick-day instructions. Above all, check ketones and acid-base status when the clinical picture suggests DKA, regardless of the glucose reading.

Frequently Asked Questions

Can a patient have DKA with normal blood sugar?

Yes. Euglycemic DKA occurs when ketoacidosis develops despite normal or only mildly elevated glucose. SGLT2 inhibitors are an important medication-related risk factor.

How long should SGLT2 inhibitors be stopped before surgery?

Current ADA guidance recommends holding most SGLT2 inhibitors for three days before elective surgery. Ertugliflozin should generally be held for four days.

What should clinicians check when euglycemic DKA is suspected?

Evaluation should include blood ketones, preferably beta-hydroxybutyrate, electrolytes, bicarbonate, acid-base status, renal function, and the anion gap. Clinical symptoms and medication history are also essential.

Should patients stop insulin when they are sick and not eating?

Patients should not independently discontinue insulin. Insulin deficiency can accelerate ketone production and precipitate DKA. Instead, patients should follow an individualized sick-day insulin plan and contact their diabetes care team when necessary.

When should an SGLT2 inhibitor be restarted after illness or surgery?

Restarting should generally wait until the acute risk has resolved and the patient is clinically stable and eating and drinking adequately. The decision should account for the reason the medication was withheld and the patient’s overall condition.

This content is not medical advice. For any health issues, always consult a healthcare professional. In an emergency, call 911 or your local emergency services.