Nov, 22 2025
Euglycemic DKA Risk Calculator
Risk Assessment Form
Enter your medical factors below to calculate your risk of euglycemic DKA (DKA with normal or slightly elevated blood sugar) while taking SGLT2 inhibitors.
Most people taking SGLT2 inhibitors for type 2 diabetes don’t think about diabetic ketoacidosis (DKA). They’re told these drugs help lower blood sugar, protect the heart, and reduce kidney damage. And they do. But there’s a quiet, dangerous side effect that doesn’t show up on routine blood tests - euglycemic DKA. This isn’t the classic DKA with blood sugar over 300 mg/dL. This one sneaks in with glucose levels under 200 mg/dL - sometimes even normal. And that’s exactly why it’s so deadly.
What Are SGLT2 Inhibitors?
SGLT2 inhibitors - like canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), and ertugliflozin (Steglatro) - work by forcing your kidneys to dump excess glucose into your urine. It’s a clever trick. Instead of relying on insulin to move sugar out of the blood, you’re letting your body flush it out naturally. That’s why these drugs also help with weight loss and blood pressure.
They’re not new. The first one, canagliflozin, got FDA approval in 2013. Since then, over 10 million people in the U.S. alone have been prescribed one of these drugs. But behind the success stories are hundreds of hospitalizations - and some deaths - tied to a complication that doesn’t fit the textbook definition of DKA.
What Is Euglycemic DKA?
Traditional DKA happens when the body runs out of insulin. Without insulin, cells can’t use glucose for energy, so they start burning fat. That produces ketones - acidic compounds that build up and poison the blood. Blood sugar is usually sky-high, over 250 mg/dL. Easy to spot.
But with SGLT2 inhibitors, the story changes. These drugs keep glucose levels low by pulling it out through urine. So even when the body starts making ketones because of stress, illness, or not eating enough, blood sugar stays near normal. That’s euglycemic DKA - DKA with normal or only slightly elevated glucose.
Here’s the problem: doctors and patients don’t look for DKA when glucose is normal. Symptoms like nausea, vomiting, abdominal pain, fatigue, and trouble breathing get blamed on the flu, food poisoning, or stress. By the time ketones are checked, it’s often too late.
How Big Is the Risk?
The numbers are scary when you look closely. Studies show SGLT2 inhibitors increase the risk of DKA by about 2.5 to 3 times compared to other diabetes drugs like DPP-4 inhibitors. One study of over 350,000 patients found 2.03 cases of DKA per 1,000 person-years with SGLT2 inhibitors, versus 0.75 with other drugs.
But here’s what’s rarely said: the absolute risk is still low. About 0.1 to 0.5 cases per 100 patient-years. That means for every 1,000 people taking these drugs for a year, maybe one or two will develop DKA. The benefits - fewer heart attacks, less kidney failure - still outweigh this risk for most people.
But low risk doesn’t mean no risk. And when it happens, it’s more dangerous. A 2021 study found the death rate from SGLT2 inhibitor-related DKA was 4.3%, compared to 2.1% for traditional DKA. Why? Because it’s missed. Patients wait too long. Doctors don’t test for ketones. By the time they do, acidosis has set in.
Who’s Most at Risk?
Not everyone on SGLT2 inhibitors will get DKA. But certain situations make it much more likely:
- Acute illness - infections, pneumonia, flu, or even a bad cold can trigger it. Your body goes into stress mode, burns fat, and makes ketones - but the drug keeps glucose low.
- Insulin dose reduction - especially in people with type 2 diabetes who have low insulin production. If you cut your insulin because your sugar is low, you’re setting yourself up for trouble.
- Surgery or fasting - even a short fast before a procedure can cause ketone buildup. The FDA and ADA now recommend stopping SGLT2 inhibitors at least 3 days before any surgery or procedure requiring fasting.
- Alcohol binges - alcohol interferes with liver glucose production and pushes the body into fat-burning mode. Combine that with an SGLT2 inhibitor, and you’ve got a perfect storm.
- Low C-peptide levels - this measures how much insulin your body still makes. People with C-peptide below 1.0 ng/mL have very little insulin reserve. In one study, 2.4% of these patients developed DKA on SGLT2 inhibitors, compared to 0.6% in those with higher levels.
One study found that nearly half of all DKA cases linked to SGLT2 inhibitors happened within the first year of starting the drug. The median time to onset? Just 28 weeks.
What Should You Do If You’re Taking One?
If you’re on an SGLT2 inhibitor, here’s what you need to know and do:
- Know the symptoms - nausea, vomiting, stomach pain, unusual fatigue, trouble breathing, confusion. Don’t wait for high blood sugar.
- Check for ketones when you’re sick - use urine strips or a blood ketone meter. If ketones are moderate or high, even if your glucose is 150 mg/dL, go to the ER. Don’t wait. Don’t call your doctor first. Go.
- Stop the drug during illness - if you’re vomiting, have a fever, or can’t eat, pause your SGLT2 inhibitor. Restart only after you’re back to normal for 24-48 hours.
- Don’t skip insulin - even if your sugar is low, don’t reduce or stop insulin unless your doctor tells you to. SGLT2 inhibitors aren’t insulin replacements.
- Talk to your doctor before surgery - make sure they know you’re on one of these drugs. Ask when to stop it. Don’t assume they’ll remember.
A 2022 study showed that when patients were taught how to check ketones and when to seek help, DKA cases dropped by 67%. Education saves lives.
What About Type 1 Diabetes?
SGLT2 inhibitors aren’t approved for type 1 diabetes - but some doctors prescribe them off-label, especially for people who are overweight or have trouble controlling blood sugar. That’s dangerous.
People with type 1 diabetes already have little to no insulin production. Adding an SGLT2 inhibitor removes glucose from the blood, but doesn’t fix the insulin shortage. That’s a recipe for DKA. The FDA and ADA warn against using these drugs in type 1 patients unless under strict supervision in a research setting.
Even then, the risk is real. A 2025 review of trials in type 1 patients found no increase in DKA compared to placebo - but those trials had intense monitoring. In real life, without constant ketone checks, the risk is much higher.
What’s Being Done About It?
Regulators are catching up. The European Medicines Agency (EMA) updated safety labels in June 2023 to explicitly warn about euglycemic DKA. The FDA added the same warning back in 2015, but many patients and providers still don’t know about it.
Now, new trials for SGLT2 inhibitors must include specific monitoring for euDKA. The FDA’s 2024 draft guidance requires it. That’s progress.
Some companies are working on dual SGLT1/SGLT2 inhibitors like licogliflozin, which may have a lower DKA risk because they slow glucose absorption in the gut, giving the body more time to adjust. Phase 3 trials are ongoing.
Meanwhile, researchers are building AI tools to predict who’s most at risk. A 2024 Lancet study created a model using 15 factors - age, C-peptide, kidney function, insulin use, recent illness - to flag high-risk patients before they even start the drug. It’s accurate 87% of the time.
Should You Stop Taking It?
No - unless your doctor tells you to.
The benefits of SGLT2 inhibitors are real. They cut heart failure hospitalizations by 30%. They slow kidney disease progression. They help you lose weight. For many, they’re life-changing.
But knowledge is power. If you’re on one of these drugs, understand the risk. Know the symptoms. Check ketones when you’re sick. Talk to your doctor about your insulin levels and your risk profile. Don’t let the fact that your blood sugar looks good fool you. DKA doesn’t always come with high numbers.
The goal isn’t to scare you off a good medication. It’s to make sure you stay safe while using it. SGLT2 inhibitors are powerful tools. But like any powerful tool, they need respect - and awareness.
Can SGLT2 inhibitors cause diabetic ketoacidosis even if my blood sugar is normal?
Yes. This is called euglycemic DKA, and it’s a known risk of SGLT2 inhibitors. Blood sugar may be under 200 mg/dL or even normal, but ketones can still build up and cause dangerous acidosis. Symptoms like nausea, vomiting, fatigue, or trouble breathing should never be ignored - check ketones immediately.
How do I check for ketones?
Use urine ketone strips (available at any pharmacy) or a blood ketone meter (like the Precision Xtra or KetoMojo). Blood ketones are more accurate. If your blood ketone level is above 0.6 mmol/L, it’s elevated. Above 1.5 mmol/L is moderate. Above 3.0 mmol/L is high - go to the ER. Don’t wait.
Should I stop my SGLT2 inhibitor if I get sick?
Yes. If you have an infection, fever, vomiting, or can’t eat for more than 24 hours, stop your SGLT2 inhibitor. Restart only after you’re fully recovered and eating normally. Check ketones during illness. This is one of the most important steps to prevent DKA.
Are SGLT2 inhibitors safe for people with type 1 diabetes?
No - not unless under strict medical supervision in a research setting. People with type 1 diabetes have little to no insulin production. SGLT2 inhibitors increase DKA risk significantly in this group. The FDA and ADA strongly advise against using them in type 1 diabetes outside of controlled trials.
When should I stop my SGLT2 inhibitor before surgery?
Stop at least 3 days before any surgery or procedure that requires fasting. This includes colonoscopies, dental surgery, or elective procedures. Talk to your doctor or surgeon ahead of time. Don’t assume they’ll know you’re on one of these drugs.
Do all SGLT2 inhibitors carry the same DKA risk?
The risk is similar across all SGLT2 inhibitors - canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. Higher doses (like 300 mg of canagliflozin) may slightly increase risk. But the main factors are patient-related: illness, insulin use, C-peptide levels, and fasting. The drug class as a whole carries this warning.
Is it safe to keep taking SGLT2 inhibitors if I’ve had DKA before?
No. If you’ve ever had DKA - even once - while on an SGLT2 inhibitor, you should not take it again. The risk of recurrence is very high. Your doctor should switch you to a different class of diabetes medication, like a GLP-1 receptor agonist or insulin.
Final Thoughts
SGLT2 inhibitors are not dangerous drugs. They’re powerful, effective tools that have changed the lives of millions. But they’re not risk-free. The biggest danger isn’t the drug itself - it’s the lack of awareness. When people think DKA only happens with high blood sugar, they miss the warning signs.
Know your body. Know your risks. Know when to act. If you’re on one of these drugs, make sure your doctor knows your insulin levels. Keep ketone strips at home. Talk to your family about the symptoms. Don’t wait for a crisis.
The goal isn’t to avoid these medications. It’s to use them safely. And that starts with knowing the hidden risk - and being ready for it.