Euglycemic DKA Risk Assessment Tool
Ketone Risk Assessment
Enter your ketone and blood sugar levels to calculate your risk of euglycemic diabetic ketoacidosis (euDKA)
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Enter your ketone and blood sugar levels to see your risk assessment
When you’re managing type 2 diabetes, a medication that lowers blood sugar, protects your heart, and reduces kidney damage sounds like a win. That’s why SGLT2 inhibitors became one of the most prescribed diabetes drugs in the last decade. But there’s a quiet, dangerous side effect many patients - and even some doctors - don’t recognize until it’s too late: diabetic ketoacidosis - even when blood sugar isn’t high.
What Are SGLT2 Inhibitors, Really?
SGLT2 inhibitors are a class of oral diabetes medications that work differently from insulin or metformin. Instead of forcing your body to use insulin better or reducing sugar production in the liver, they tell your kidneys to flush out extra glucose through urine. That’s it. Simple. Effective. Drugs like canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), and ertugliflozin (Steglatro) have helped millions cut their HbA1c, lose weight, and lower their risk of heart failure.
But here’s the catch: when your kidneys are dumping glucose, they’re also changing how your body handles fuel. With less glucose available, your body starts breaking down fat for energy - producing ketones. Normally, that’s fine. But with SGLT2 inhibitors, this process can go too far, too fast - even when your blood sugar looks normal.
The Silent Killer: Euglycemic DKA
Traditional diabetic ketoacidosis (DKA) looks like this: blood sugar over 250 mg/dL, fruity breath, nausea, confusion, rapid breathing. It’s obvious. Emergency room staff know it instantly.
But SGLT2 inhibitor-related DKA? That’s different. It’s called euglycemic DKA - or euDKA. Blood sugar? Often below 200 mg/dL. Sometimes even under 150 mg/dL. That’s not even in the "high" range. So you don’t panic. You think, "My sugar’s fine, I must just have the flu."
That’s when things turn dangerous. A 2023 analysis of over 1,200 reported cases found nearly half of DKA events linked to SGLT2 inhibitors had blood glucose below 250 mg/dL. The median time to onset? Just 28 weeks after starting the drug. And because doctors aren’t looking for DKA when glucose is normal, diagnosis is delayed - sometimes by days. The mortality rate for euDKA is 4.3%, nearly double that of classic DKA.
Why Does This Happen?
It’s not just about the drug. It’s about what happens when the drug meets real life.
SGLT2 inhibitors reduce insulin demand. Your pancreas doesn’t need to work as hard. But if you get sick - say, with the flu or a stomach bug - your body goes into stress mode. Cortisol and adrenaline spike. Your liver dumps more glucose. Your muscles stop taking up glucose. Your insulin levels drop. Meanwhile, your kidneys are still flushing out sugar. The result? A perfect storm for ketone overproduction.
Other triggers? Skipping meals. Cutting carbs too hard. Drinking alcohol. Going without insulin (especially if you have type 1 or severe type 2 with low insulin production). Surgery. Even intense exercise without enough fuel.
One study found that patients with C-peptide levels below 1.0 ng/mL - meaning their pancreas barely makes any insulin - had a 4x higher risk of euDKA than those with normal insulin production. That’s why SGLT2 inhibitors are not recommended for people with type 1 diabetes unless under strict supervision - and even then, it’s risky.
Who’s at Highest Risk?
Not everyone on SGLT2 inhibitors gets euDKA. But certain people are far more vulnerable:
- Those with low insulin production (low C-peptide)
- People who recently reduced or stopped insulin
- Patients with a history of DKA
- Those on high doses (like 300 mg of canagliflozin)
- Anyone with an acute illness - infection, vomiting, diarrhea
- People preparing for surgery or fasting
- Those drinking heavily or on very low-carb diets
And here’s something most don’t realize: the risk peaks early. Over 60% of euDKA cases happen within the first year of taking the drug. That’s when patients are still adjusting - and when doctors may not yet be watching for this specific warning sign.
What the Experts Say - And What You Should Do
The European Medicines Agency (EMA), the FDA, and the American Diabetes Association all agree: euDKA is real. It’s underdiagnosed. And it’s deadly if missed.
Here’s what they recommend:
- Stop SGLT2 inhibitors at least 3 days before surgery or any procedure requiring fasting. Don’t wait until the day before. Your body needs time to reset.
- Check ketones if you feel unwell. Nausea? Vomiting? Abdominal pain? Fatigue? Shortness of breath? Even if your glucose is 140 mg/dL - test your ketones. Use urine strips or a blood ketone meter. Anything above 0.6 mmol/L is a red flag. Above 1.5? Go to the ER.
- Never stop insulin without medical advice. If you’re on both insulin and an SGLT2 inhibitor, don’t reduce insulin because your sugar looks good. That’s how euDKA starts.
- Know your C-peptide level. If you’re considering an SGLT2 inhibitor, ask your doctor to test it. If it’s low, this drug might not be safe for you.
- Don’t follow extreme low-carb diets. Ketosis is normal on keto. But ketosis + SGLT2 inhibitors = danger zone.
A 2022 study showed that when patients were taught to check ketones during illness, DKA rates dropped by 67%. Education saves lives.
The Numbers Don’t Lie - But They Don’t Tell the Whole Story
Some studies say SGLT2 inhibitors don’t increase DKA risk. Others say they triple it. Why the confusion?
Because many trials compare SGLT2 inhibitors to placebo or DPP-4 inhibitors - not insulin. And in people with strong insulin production, the risk is low. But in real-world use - where patients are older, sicker, on multiple meds, skipping meals, or reducing insulin - the risk climbs.
The absolute risk? About 0.1 to 0.5 cases per 100 patients per year. That sounds small. But when you consider how many people are on these drugs - millions - that’s hundreds of preventable hospitalizations and dozens of deaths each year.
And here’s the trade-off: these drugs reduce heart failure hospitalizations by 30% and slow kidney decline. For many, the benefits outweigh the risks. But only if you know the warning signs - and act before it’s too late.
What’s Next? New Drugs, Better Tools
Pharmaceutical companies are already working on solutions. One new drug, licogliflozin, targets both SGLT1 and SGLT2. Early data suggests it may cause fewer ketones because it slows sugar absorption in the gut, reducing the body’s need to burn fat.
Meanwhile, machine learning models are being trained to predict who’s at risk. A 2024 study used 15 clinical factors - age, kidney function, insulin use, HbA1c, BMI - to create a tool that predicts euDKA risk with 87% accuracy. Soon, your doctor might get an alert before prescribing an SGLT2 inhibitor if you’re in the danger zone.
For now, the message is simple: SGLT2 inhibitors are powerful - but not risk-free. They’re not magic pills. They’re tools. And like any tool, they need to be used wisely.
What to Do If You’re on an SGLT2 Inhibitor
If you’re taking one of these drugs, here’s your action plan:
- Ask your doctor for your C-peptide level. If it’s below 1.0 ng/mL, discuss alternatives.
- Keep ketone test strips at home. Buy a blood ketone meter if you can - they’re more accurate than urine strips.
- Write down the symptoms: nausea, vomiting, stomach pain, tiredness, trouble breathing, confusion.
- Test ketones the moment you feel sick - even if your sugar is normal.
- Stop the drug before any surgery, hospital visit, or prolonged fast.
- Never reduce insulin without talking to your care team.
- Teach a family member how to check your ketones and recognize the signs.
There’s no shame in asking for help. The goal isn’t to avoid these drugs - it’s to use them safely. For most people, that’s possible. But only if you know what to watch for.
Can SGLT2 inhibitors cause diabetic ketoacidosis even if my blood sugar is normal?
Yes. This is called euglycemic diabetic ketoacidosis (euDKA). Blood sugar can be below 200 mg/dL - sometimes even under 150 mg/dL - while ketones rise dangerously. This makes it easy to miss because it doesn’t look like classic DKA. If you feel sick, nausea, vomiting, or abdominal pain while on an SGLT2 inhibitor, check your ketones immediately - regardless of your blood sugar level.
Which SGLT2 inhibitors carry the highest risk of DKA?
All SGLT2 inhibitors - including canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin - carry this risk. However, higher doses (like 300 mg of canagliflozin) increase the risk more than lower doses. There’s no clear evidence that one drug is safer than another for euDKA. The risk comes from the class, not a single brand.
Should I stop taking my SGLT2 inhibitor if I get sick?
Yes - and this is critical. If you have an infection, flu, vomiting, diarrhea, or any illness that reduces your food intake, stop your SGLT2 inhibitor immediately. Contact your doctor. Do not wait. Restart only when you’re eating normally and feeling better. The same applies before any surgery - stop at least 3 days ahead of time.
Can I use SGLT2 inhibitors if I have type 1 diabetes?
SGLT2 inhibitors are not approved for type 1 diabetes in most countries. However, some doctors prescribe them off-label for select patients who are struggling with weight or insulin resistance - but only under strict supervision. The risk of euDKA is significantly higher in type 1 diabetes because insulin production is already very low. If you have type 1 and are considering this drug, discuss the risks thoroughly with your endocrinologist.
How can I check for ketones at home?
You can use urine ketone strips (available at pharmacies) or a blood ketone meter (like the Precision Xtra or Nova Max Plus). Blood ketone testing is more accurate. A reading above 0.6 mmol/L is elevated. Above 1.5 mmol/L is dangerous and requires urgent medical care. If you’re on an SGLT2 inhibitor, keep ketone strips or a meter at home - especially during flu season or before surgery.
Are there safer alternatives to SGLT2 inhibitors?
Yes. Metformin remains the first-line treatment for type 2 diabetes and carries no DKA risk. GLP-1 receptor agonists like semaglutide (Wegovy, Ozempic) and liraglutide (Victoza) also reduce heart and kidney risk without increasing DKA. DPP-4 inhibitors like sitagliptin are another option with a very low risk profile. Talk to your doctor about whether one of these might be safer for you - especially if you have low insulin production or other risk factors.
Final Thought: Knowledge Is Your Best Defense
SGLT2 inhibitors are not the enemy. For many, they’ve been life-changing. But they’re not risk-free. The biggest danger isn’t the drug - it’s the assumption that "normal blood sugar means everything’s fine." That mindset kills. If you’re on one of these medications, don’t wait for a warning label to tell you what to do. Learn the signs. Test your ketones. Ask the hard questions. Your life might depend on it.