# Ketoacidosis can hide behind a modest glucose

SGLT2 therapy, poor intake, and illness can uncouple glucose from ketones

Andrew Bland, MD, FACP, FAAP · October 20, 2026

![ Ketoacidosis can hide behind a modest glucose ](https://urinenephrology.org/2025_UDPA_Lectures_Live/assets/day1-edka-potassium-2026-10-20.png)

## Glucose and ketones can diverge

SGLT2 inhibition reduces proximal tubular glucose reabsorption. Glycosuria moderates the blood glucose reading while illness, reduced intake and relative insulin deficiency can promote lipolysis and hepatic ketone production. In Case 3, glucose is 206 mg/dL and beta-hydroxybutyrate is 5.8 mmol/L. This is SGLT2-associated ketoacidosis with modest glucose; 206 is just above the 2024 consensus definition of euglycemic DKA at glucose below 200.

## Potassium can fall rapidly during treatment

Poor intake and urinary losses can deplete body potassium even when the serum result does not look severely low. Insulin moves potassium from blood into cells. Check and correct low potassium before insulin under a monitored protocol, then reassess repeatedly as treatment proceeds.

## Treat ketogenesis and follow the right endpoints

Insulin stops ketone production; dextrose supports continued insulin when glucose is already modest or falls. Follow blood ketones, pH or bicarbonate, electrolytes and clinical status. Anion gap alone can mislead during recovery, especially after chloride-rich fluids. Hold the SGLT2 inhibitor and use the case's separate specialist review before any restart.

## Discussion

Why is a glucose of 206 insufficient to dismiss DKA in Case 3?

The SGLT2 drug promotes urinary glucose loss. Ketones and acidosis can remain substantial even with modest glucose; blood beta-hydroxybutyrate directly tests the suspected ketone burden.

## Sources

- [Source case](https://urinenephrology.org/2025_UDPA_Lectures_Live/case-based-lectures/cbl-03-the-sick-day-that-wasn-t-held.html)
- [Metabolic acidosis lecture](https://urinenephrology.org/2025_UDPA_Lectures_Live/electrolytes/acid-base/metabolic-acidosis.html)
- [SGLT2-associated ketoacidosis review](https://urinenephrology.org/mastery/acid-base/sglt2-edka.html)
- [2024 consensus report on hyperglycemic crises](https://doi.org/10.2337/dci24-0032)

For education. Read alongside the full case and lecture; use clinical judgment.