How to manage a T2DM patient off empagliflozin (Jardiance) and gliclazide (Gliclazide), with BGL 5.3 mmol/L and ketones 2.9 mmol/L, on maintenance fluids?

Management of Euglycemic Diabetic Ketoacidosis in T2DM Patient Off SGLT2 Inhibitor

This patient has euglycemic diabetic ketoacidosis (euDKA), most likely precipitated by recent empagliflozin use combined with acute illness and inadequate oral intake, requiring immediate hospital admission for intravenous fluid resuscitation, insulin therapy, and close monitoring of ketones and electrolytes. 1, 2

Immediate Recognition and Severity Assessment

This clinical presentation meets criteria for euglycemic DKA:

• Blood glucose 5.3 mmol/L (<10 mmol/L) with elevated ketones 2.9 mmol/L (moderate-to-high range) 1
• Patient is on maintenance IV fluids, suggesting inability to maintain adequate oral intake 1
• Recent discontinuation of empagliflozin and gliclazide indicates acute illness management 1, 2

The combination of SGLT2 inhibitor exposure (even if recently stopped), reduced oral intake (puree diet), and maintenance fluids creates the perfect storm for euDKA. 1, 2

Critical Management Steps

Immediate Actions Required

Admit to hospital for inpatient management with the following priorities: 1

• Volume resuscitation with intravenous normal saline - Start aggressive fluid replacement to reverse volume depletion and improve tissue perfusion 1
• Initiate insulin therapy immediately - Start continuous insulin infusion at 0.1 units/kg/hour or subcutaneous insulin at 0.3-0.4 units/kg/day divided as basal-bolus regimen 1
• Add dextrose to IV fluids once blood glucose approaches 11-14 mmol/L to prevent hypoglycemia while continuing insulin to clear ketones 1
• Monitor ketones every 2-4 hours until they normalize (<0.6 mmol/L) 1
• Check electrolytes (particularly potassium) every 2-4 hours and replace as needed 1

Why This Patient Developed euDKA

SGLT2 inhibitors like empagliflozin increase ketoacidosis risk through multiple mechanisms: 1, 2

• Increased glucagon secretion and decreased insulin secretion promote ketogenesis 1
• Reduced renal ketone clearance due to SGLT2 inhibition 2
• Volume depletion from osmotic diuresis 1, 2

The "sick day" scenario amplified this risk: 1, 2

• Puree diet suggests reduced oral intake (anorexia/dysphagia) 1
• Maintenance IV fluids indicate inability to maintain hydration orally 1
• Withholding usual diabetes medications removed glucose-lowering effect but ketone production continued 1, 2

Insulin Therapy Protocol

Long-acting insulin alone is insufficient for euDKA - this patient requires either continuous IV insulin or multiple daily injections: 1

• IV insulin infusion (preferred for moderate-to-high ketones): Start at 0.1 units/kg/hour, continue until ketones <0.6 mmol/L and anion gap closes 1
• Subcutaneous basal-bolus regimen (if IV not feasible): Total daily dose 0.3-0.4 units/kg/day, with 50% as long-acting basal insulin and 50% divided as rapid-acting prandial insulin 1
• Add dextrose 5-10% to IV fluids when glucose reaches 11-14 mmol/L to maintain glucose in target range while continuing insulin to clear ketones 1

Medication Management Going Forward

What to Permanently Stop

Do NOT restart empagliflozin in this patient: 1, 2, 3

• SGLT2 inhibitors should be held during acute illness to prevent volume depletion 1, 2
• Should be discontinued at least 3 days before planned surgery or procedures 2, 3
• This patient has demonstrated SGLT2 inhibitor-associated ketoacidosis, which is a relative contraindication to restarting 1, 4

What to Resume After Recovery

Gliclazide (sulfonylurea) can be resumed once: 1

• Patient is eating and drinking normally 1
• Symptoms have resolved 1
• Resume at usual dose within 24-48 hours of normal oral intake 1

If patient took gliclazide before developing symptoms, monitor for delayed hypoglycemia for 12-24 hours as the medication effect persists 1

Monitoring During Hospitalization

Check the following parameters: 1

• Ketones every 2-4 hours until <0.6 mmol/L 1
• Blood glucose every 1-2 hours during insulin infusion, then every 4-6 hours on subcutaneous insulin 1
• Electrolytes (especially potassium) every 2-4 hours initially, then every 6 hours once stable 1
• Arterial or venous blood gas if acidosis suspected (pH, bicarbonate, anion gap) 1

Transition to Discharge

Criteria for transitioning off IV insulin: 1

• Ketones <0.6 mmol/L for at least 6 hours 1
• Anion gap normalized 1
• Patient tolerating oral intake 1
• pH >7.3 if measured 1

Discharge planning: 1

• Resume gliclazide at usual dose once eating normally 1
• Consider alternative to empagliflozin (metformin, DPP-4 inhibitor, or GLP-1 agonist if cardiovascular benefit needed) 1
• Provide "sick day rules" education: hold SGLT2 inhibitors (if ever restarted), maintain hydration, seek help if unable to eat/drink for >24 hours 1, 2
• Ensure patient understands symptoms requiring urgent medical attention: vomiting >4 times in 12 hours, confusion, rapid breathing, inability to keep fluids down 1

Common Pitfalls to Avoid

Do not assume normal glucose excludes DKA - euglycemic DKA is a recognized complication of SGLT2 inhibitors where ketoacidosis develops despite glucose <14 mmol/L 1, 4

Do not stop insulin when glucose normalizes - continue insulin (with dextrose supplementation) until ketones clear, as premature insulin cessation will perpetuate ketogenesis 1

Do not restart empagliflozin without careful risk-benefit assessment - this patient has demonstrated susceptibility to SGLT2 inhibitor-associated ketoacidosis 1, 2, 4

Do not discharge until ketones have normalized - persistent ketonemia indicates ongoing metabolic derangement requiring continued treatment 1