What are the guidelines for a diabetic patient on Invokana (canagliflozin) with nausea, dizziness, stomach pain, and reduced oral intake for 5 days or less?

Immediate Action Required: Hold Invokana and Evaluate for Diabetic Ketoacidosis

This patient requires immediate discontinuation of Invokana (canagliflozin) and urgent evaluation for diabetic ketoacidosis (DKA), which can occur even with normal or mildly elevated blood glucose levels. The combination of nausea, abdominal pain, dizziness, and reduced oral intake in a patient on an SGLT2 inhibitor represents classic warning signs of euglycemic DKA, a potentially life-threatening complication 1.

Immediate Management Steps

Stop Invokana Immediately

• Discontinue canagliflozin now - the FDA label specifically states to withhold the medication when patients have low oral intake 2
• The American College of Cardiology guidelines explicitly instruct patients to "hold medication if low oral intake" 1
• Do not wait for laboratory confirmation before stopping the drug 1

Urgent Laboratory Evaluation Required

Obtain the following tests immediately to rule out DKA:

• Arterial or venous blood gas to assess for metabolic acidosis (pH <7.3) 3, 4
• Serum beta-hydroxybutyrate (preferred) or urine ketones 1
• Anion gap calculation from basic metabolic panel 3, 4
• Blood glucose - remember that DKA can occur with glucose levels as low as 150-250 mg/dL with SGLT2 inhibitors 1
• Serum electrolytes, BUN, and creatinine 1

Why This Presentation is High-Risk

Euglycemic DKA is a Known Complication

• SGLT2 inhibitors like canagliflozin cause DKA that presents with normal or only mildly elevated glucose (often <250 mg/dL), making it easily missed 3, 4, 5
• The classic triad of symptoms—nausea, vomiting, and abdominal pain—combined with reduced oral intake are the exact precipitating factors for SGLT2 inhibitor-associated DKA 1
• Case reports document fatal outcomes when this diagnosis is delayed 2

Volume Depletion Compounds the Risk

• Dizziness suggests hypovolemia, which is exacerbated by canagliflozin's diuretic effect 1
• The combination of reduced oral intake and ongoing urinary glucose losses creates a dangerous volume-depleted state 5
• Volume depletion triggers glucagon secretion, which further promotes ketoacidosis 5

Clinical Decision Algorithm

If laboratory testing is immediately available (within 1 hour):

• Hold Invokana now
• Obtain blood gas, ketones, and basic metabolic panel
• If pH <7.3, ketones elevated, or anion gap >12: admit for DKA management with IV fluids and insulin infusion 1, 3
• If testing is normal: keep Invokana held until oral intake normalizes for at least 24-48 hours 2

If laboratory testing is delayed or unavailable:

• Hold Invokana immediately
• Send patient to emergency department for evaluation given the high-risk symptom constellation 3, 6
• Do not restart canagliflozin until the acute illness resolves and normal oral intake resumes 2

Critical Pitfalls to Avoid

Do Not Be Falsely Reassured by Normal Glucose

• The most dangerous error is dismissing DKA because glucose is not markedly elevated 3, 4, 6
• SGLT2 inhibitors cause "euglycemic DKA" where glucose may be 150-250 mg/dL or even lower 1
• Always check ketones and blood gas in symptomatic SGLT2 inhibitor users regardless of glucose level 3, 6

Recognize Prolonged Drug Effects

• Canagliflozin's effects persist for 3 days after discontinuation, with glucosuria potentially lasting up to 2 weeks 2
• Even after stopping the drug, monitor for ongoing volume depletion from persistent urinary glucose losses 4
• The FDA label mandates withholding canagliflozin at least 3 days before any procedure with prolonged fasting 2

When to Resume Invokana

Do not restart canagliflozin until ALL of the following are met:

• Patient is clinically stable with resolved nausea and abdominal pain 2
• Normal oral intake has been maintained for at least 24-48 hours 2
• No evidence of ketosis or acidosis on repeat testing 1
• Patient has been re-educated about warning signs and the need to hold medication during illness 1

Patient Education for Future Prevention

The American College of Cardiology guidelines emphasize educating patients to:

• Recognize DKA symptoms: nausea, vomiting, abdominal pain, weakness 1
• Hold canagliflozin immediately if unable to maintain normal oral intake 1
• Seek urgent medical attention if DKA-like symptoms develop 1
• Understand that DKA can occur even with normal home glucose readings 1