How should I monitor for Jardiance (Empagliflozin) associated diabetic ketoacidosis?

Monitoring for Jardiance (Empagliflozin) Associated Ketoacidosis

Blood β-hydroxybutyrate (bOHB) measurement is the preferred method for monitoring patients on Jardiance (empagliflozin) for ketoacidosis, as it directly measures the predominant ketone body in diabetic ketoacidosis (DKA). 1

Key Monitoring Recommendations

When to Monitor

• Patients taking SGLT2 inhibitors like Jardiance should check ketones if they experience:
  • Unexplained hyperglycemia 2
  • Symptoms consistent with ketoacidosis (nausea, vomiting, abdominal pain, tiredness, labored breathing) even if blood glucose is not elevated 3
  • Any sign of illness 1

Preferred Testing Method

• Blood β-hydroxybutyrate (bOHB) testing is superior to urine ketone testing for both diagnosis and monitoring of DKA 1, 4
• Blood bOHB measurement can detect ketosis earlier than traditional nitroprusside methods 4

Important Considerations for SGLT2 Inhibitor-Associated DKA

• Jardiance can cause euglycemic DKA, where ketoacidosis occurs without significantly elevated blood glucose levels 3, 5
• Patients may develop DKA with blood glucose <250 mg/dL while on SGLT2 inhibitors, making traditional hyperglycemia-based monitoring insufficient 5, 6

Diagnostic Parameters for DKA

If ketoacidosis is suspected, the following parameters should be evaluated:

• Blood glucose (may be <250 mg/dL in euglycemic DKA) 4, 5
• Blood β-hydroxybutyrate levels 1
• Venous pH (<7.3 indicates DKA) 4
• Serum bicarbonate (<18 mEq/L indicates DKA) 4
• Anion gap (elevated in DKA) 4

Monitoring During Treatment of DKA

If DKA is diagnosed, monitor:

• Blood glucose, electrolytes, BUN, creatinine, venous pH, and anion gap every 2-4 hours 7, 4
• Blood bOHB levels to track ketosis resolution 4
• Resolution criteria: glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 7, 4

Important Warnings and Precautions

• Nitroprusside-based ketone tests (urine or blood) should NOT be used for monitoring treatment of DKA as they only measure acetoacetic acid and acetone, not β-hydroxybutyrate 1
• During DKA treatment, β-hydroxybutyrate is converted to acetoacetate, which may falsely suggest worsening ketosis when using nitroprusside-based tests 8
• Patients should be instructed to discontinue Jardiance and seek immediate medical attention if symptoms of ketoacidosis occur 3

Patient Education Points

• Educate patients about symptoms of ketoacidosis: nausea, vomiting, abdominal pain, fatigue, and labored breathing 3
• Teach patients how to monitor blood ketone levels when ill, even if blood glucose is normal 1, 3
• Emphasize that ketoacidosis while on Jardiance can occur with near-normal blood glucose levels 3, 5
• Instruct patients to maintain adequate hydration and to temporarily discontinue Jardiance during acute illness with reduced oral intake or increased fluid losses 3

Risk Factors for SGLT2 Inhibitor-Associated DKA

• Reduced insulin doses or insulin deficiency 9
• Reduced caloric or fluid intake 3
• Acute illness or infection 9
• Surgery or trauma 9
• Alcohol consumption 10
• Type 1 diabetes (higher risk when SGLT2 inhibitors are used off-label) 1