# SGLT2-Associated Ketoacidosis: Glucose Can Mislead

Glycosuria and ketosis may persist after the last dose. Treatment resolution depends on acid–base and ketone recovery, not glucose alone.

![Infographic: SGLT2-Associated Ketoacidosis: Glucose Can Mislead](https://urinenephrology.org/visual-reference/images/mastery-edka.png?v=20261003c)

## Ketones despite modest glucose

SGLT2 inhibition can promote ketogenesis while urinary glucose loss limits hyperglycemia. A reassuring glucose value does not exclude dangerous ketoacidosis.

## Recognize the setting

Fasting, surgery, acute illness, reduced insulin delivery, dehydration, and marked carbohydrate restriction increase concern. Type 1 diabetes presents additional risk and regulatory limitations.

## Test ketones despite normal glucose

In an SGLT2 user with nausea, abdominal pain, tachypnea, or unexplained illness, check blood beta-hydroxybutyrate and acid–base status even when glucose is not markedly elevated. Stop the SGLT2 inhibitor when ketoacidosis is suspected; investigate infection, fasting, and missed insulin.

## Treat urgently

Stop the implicated medication and use an appropriate supervised ketoacidosis protocol. Insulin, carbohydrate, fluid, and potassium decisions must follow the patient's evolving physiology.

## Plan procedures and illness

Empagliflozin labeling calls for withholding at least 3 days before surgery or prolonged-fasting procedures when possible. Follow the actual agent label; intervals are not identical across the class. Resume only when clinically stable and eating. Do not omit necessary basal insulin simply because glucose is normal.

## Avoid false reassurance

Glycosuria and ketosis may persist after the last dose. Treatment resolution depends on acid–base and ketone recovery, not glucose alone.

## Supporting evidence

- [Supporting guideline or source](https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/204629s063lbl.pdf)

## Source lessons

- [sglt2 edka](https://urinenephrology.org/mastery/acid-base/sglt2-edka.html)
- [sglt2 type1 diabetes](https://urinenephrology.org/mastery/cardiorenal/sglt2-type1-diabetes.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.