A fictional 48-year-old with type 2 diabetes taking dapagliflozin presents after vomiting and very limited intake. They are tachypnoeic and drowsy; glucose is 11.2 mmol/L, blood ketones 4.2 mmol/L, venous pH 7.18 and bicarbonate 10 mmol/L.
Listen for the assumption.
The glucose is only 11.2, so I ruled out diabetic ketoacidosis.
The ketonaemia and metabolic acidosis define the danger. SGLT2 inhibitors can keep glucose only moderately raised while ketoacidosis develops.
I will stop dapagliflozin, start the local DKA pathway and use glucose-containing fluid as needed so insulin can continue safely to clear ketones.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Blood ketones 4.2 mmol/L
- Venous pH 7.18 and bicarbonate 10 mmol/L
- Dapagliflozin continued during vomiting and restricted intake
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Use the current JBDS/local DKA protocol, replace fluid and potassium appropriately, monitor ketones and pH, and look for precipitating illness.
Do not improvise exact infusion rates outside the protocol. Involve the diabetes team and ensure basal insulin and transition decisions are actively reviewed.
I will hand over ketone and pH trajectories, insulin and glucose infusions, potassium, precipitant and the SGLT2-inhibitor plan.
What must remain explicit.
- Use the current local/JBDS adult DKA protocol.
- Monitor glucose, blood ketones, pH, potassium and fluid status at protocol-defined intervals.
- Seek senior/critical-care review for severe acidosis, altered consciousness or deterioration.
Where reasoning fails.
- Excluding DKA because glucose is below 14 mmol/L
- Stopping insulin before ketosis resolves
- Restarting the SGLT2 inhibitor without specialist review
SGLT2-associated euglycaemic DKA with glucose [trend], ketones/pH/bicarbonate [trend], insulin/glucose/potassium [current therapy], fluid balance [status], precipitant [assessment] and medicine plan [details].
Does your acute clerking prompt ketone testing in an unwell person taking an SGLT2 inhibitor despite near-normal glucose?