What dextrose regimen should be administered to a patient with Type 2 Diabetes Mellitus, elevated ketones, and a blood sugar level of 5.6 mmol/L, who has not taken empagliflozin and gliclazide today?

Management of Euglycemic Diabetic Ketoacidosis in T2DM Patient on SGLT2 Inhibitor

This patient has euglycemic diabetic ketoacidosis (euDKA) secondary to empagliflozin, and you should administer 10% dextrose at 100-125 mL/hour alongside an insulin infusion to suppress ketogenesis while preventing hypoglycemia.

Immediate Recognition and Diagnosis

• This clinical presentation—ketones 2.9 mmol/L with normal blood glucose (5.6 mmol/L) and normal pH (7.41) in a patient on empagliflozin with minimal oral intake—represents euglycemic diabetic ketoacidosis, a well-documented complication of SGLT2 inhibitors 1
• Euglycemic DKA is characterized by blood glucose <13.9 mmol/L (250 mg/dL), arterial pH <7.35, and presence of ketones in blood or urine 1
• While this patient's pH is currently normal at 7.41, the significantly elevated ketones (2.9 mmol/L) with minimal oral intake and missed medications indicate evolving metabolic decompensation requiring immediate intervention 1

Dextrose Administration Protocol

• Administer 10% dextrose intravenously at 100-125 mL/hour (10-12.5 grams/hour) to provide substrate for glucose metabolism and suppress ketogenesis 2
• The dextrose infusion must be started simultaneously with insulin therapy, as insulin alone will drive blood glucose dangerously low while ketones remain elevated 2
• Continue dextrose infusion until ketones normalize (<0.6 mmol/L) and the patient resumes adequate oral intake, even if blood glucose rises to 10-14 mmol/L (180-250 mg/dL) 2

Concurrent Insulin Therapy

• Start an insulin infusion at 0.05-0.1 units/kg/hour to suppress ketogenesis, as insulin is required to halt lipolysis and ketone production regardless of blood glucose level 2
• Monitor blood glucose every 1-2 hours and adjust dextrose concentration (5%, 10%, or even 20%) to maintain blood glucose between 8-12 mmol/L (140-220 mg/dL) while continuing insulin to clear ketones 2

Critical Management Steps

• Immediately discontinue empagliflozin and do not restart it—this patient should never receive SGLT2 inhibitors again 1
• Provide aggressive intravenous fluid resuscitation with normal saline at 250-500 mL/hour initially (adjusted for age and cardiac status) to correct volume depletion from osmotic diuresis 1
• Monitor electrolytes every 2-4 hours, particularly potassium, as insulin therapy will drive potassium intracellularly and may require aggressive repletion 2

Common Pitfalls to Avoid

• Do not withhold dextrose because the blood glucose is "normal"—this is the defining feature of euglycemic DKA and requires dextrose to resolve ketosis 1
• Do not rely on sliding scale insulin alone without basal insulin coverage, as this approach is strongly discouraged and ineffective for metabolic management 3, 4
• Do not delay treatment waiting for pH to drop further—elevated ketones with minimal oral intake in an SGLT2 inhibitor user requires immediate intervention before full metabolic decompensation occurs 1
• Avoid restarting gliclazide until the patient is eating normally, as sulfonylureas increase hypoglycemia risk when combined with insulin therapy and reduced oral intake 2, 3

Monitoring and Transition

• Continue monitoring ketones every 2-4 hours until they normalize to <0.6 mmol/L 1
• Once ketones clear and the patient tolerates oral intake, transition from intravenous insulin to subcutaneous basal-bolus insulin regimen 3
• Resume metformin when oral intake is adequate, but permanently discontinue empagliflozin given this serious adverse event 1
• Consider alternative glucose-lowering agents such as GLP-1 receptor agonists once metabolically stable, as these do not carry the euDKA risk 2