Euglycemic DKA Risk Assessment Tool
Symptom Assessment
This tool helps determine if you need immediate medical attention based on symptoms and risk factors.
Results will appear here...
EMERGENCY ALERT: This is a medical emergency. Call 911 immediately.
Important: Even with normal blood sugar, ketone testing is critical when using SGLT2 inhibitors. The FDA requires immediate medical attention for any symptoms of ketoacidosis, regardless of blood sugar levels.
Most people think diabetic ketoacidosis (DKA) means high blood sugar-usually over 250 mg/dL. But if you're taking an SGLT2 inhibitor like Farxiga, Jardiance, or Invokana, that assumption can be deadly. You can have full-blown DKA with blood sugar levels as low as 100 mg/dL. This is called euglycemic DKA, and itâs slipping through the cracks in emergency rooms across the country.
What Is Euglycemic DKA?
Euglycemic diabetic ketoacidosis (EDKA) is a dangerous form of DKA that happens when your body makes too many ketones-acidic fuel molecules-while your blood sugar stays normal or only slightly elevated. Itâs not rare. Studies show it makes up 2.6% to 3.2% of all DKA cases. And among people on SGLT2 inhibitors, the risk is seven times higher than in those not taking these drugs. SGLT2 inhibitors work by making your kidneys flush out extra sugar through urine. That sounds good for lowering blood sugar, but hereâs the catch: your body thinks itâs running low on fuel. In response, your pancreas releases more glucagon and less insulin. That imbalance forces your fat cells to break down into ketones, even if your glucose levels look fine. The result? Acidosis without the red flag of high blood sugar.Why Itâs So Hard to Spot
The biggest problem with EDKA is that it doesnât look like classic DKA. Patients show up with nausea, vomiting, abdominal pain, and extreme fatigue-symptoms that could be mistaken for the flu, food poisoning, or even a stomach bug. Many patients and even some doctors assume, âMy blood sugar is normal, so Iâm fine.â Thatâs the trap. A 2015 study in Diabetes Care followed 13 cases of EDKA linked to SGLT2 inhibitors. In every case, the patients were initially dismissed because their glucose levels were below 250 mg/dL. One patient died before the diagnosis was made. Another was hospitalized for three days because no one checked for ketones. The FDA issued a boxed warning in 2015, but awareness hasnât kept up. Emergency departments still rely on glucose levels to rule out DKA. Thatâs outdated. EDKA doesnât wait for your sugar to spike before it starts damaging your organs.Whoâs at Risk?
You donât have to have type 1 diabetes to get EDKA. While itâs more common in type 1 patients, about 20% of cases occur in people with type 2 diabetes whoâve never had DKA before. Risk factors include:- Illness (like the flu, pneumonia, or a UTI)
- Fasting or drastically cutting carbs
- Surgery or major stress
- Alcohol use
- Pregnancy
- Stopping insulin (even temporarily)
How Itâs Diagnosed
If youâre on an SGLT2 inhibitor and feel sick, donât wait for your glucose to climb. Test for ketones-right away. The diagnosis requires three things:- Blood glucose below 250 mg/dL
- Metabolic acidosis (pH below 7.3 or bicarbonate below 18 mEq/L)
- Elevated ketones (blood beta-hydroxybutyrate over 3 mmol/L)
Emergency Treatment: What Works
Treatment follows the same principles as classic DKA-but with key differences. Fluids first: Start with 0.9% saline at 15-20 mL/kg in the first hour. Dehydration is severe, even if you donât look it. But donât overdo it-fluid overload can cause brain swelling. Insulin is still needed: Give 0.1 units/kg/hour of IV insulin. But hereâs the twist: you need to add dextrose much sooner than in hyperglycemic DKA. Because your blood sugar is already low, insulin will drop it even further. Once glucose hits 150-200 mg/dL, switch to 5% dextrose in saline to keep it stable while ketones clear. Watch your potassium: Your serum potassium might look normal, but your total body potassium is usually low. Youâll lose it fast once insulin starts working. Replace it early and often. About 65% of EDKA patients need potassium supplementation. Donât confuse it with lactic acidosis: Some patients also have elevated lactate. Check both ketones and lactate to avoid misdiagnosis.
Prevention: What You Can Do
The best way to avoid EDKA is to know when to pause your SGLT2 inhibitor.- Stop taking it if youâre sick, fasting, or having surgery.
- Keep eating carbs-even if youâre not hungry. Your body needs fuel.
- Check ketones with a blood meter during illness, even if your glucose is normal.
- Donât rely on urine strips. Theyâre slow and unreliable.
- Talk to your doctor before stopping insulin, even for a day.
Phoebe McKenzie
January 3, 2026 AT 01:54This is why people shouldn't be allowed to take SGLT2 inhibitors without a PhD in endocrinology. I've seen so many patients nearly die because they thought 'normal glucose' meant 'safe'-it's not just negligence, it's criminal. Doctors are lazy and patients are clueless. The FDA warning is a joke if it's not enforced with mandatory training. Someone needs to sue the pharmaceutical companies for this. I'm not even mad, I'm just disappointed.
gerard najera
January 5, 2026 AT 00:09Ketones don't care about glucose numbers.
Stephen Gikuma
January 6, 2026 AT 08:38Big Pharma pushed these drugs because they knew people would get sick and then need more meds. They're not trying to help-they're trying to hook you. Look at the timeline: 2015 warning, and now 41% of cases are EDKA? That's not progress, that's a marketing success. They're using your body as a lab. The government lets them do this because they're too busy taking bribes. You think your insulin is safe? Think again.
Bobby Collins
January 8, 2026 AT 03:12okay but like... what if you're just trying to lose weight and you're on this drug and you get sick and your sugar is normal and you think you're fine but you're actually dying?? like?? why is this even a thing?? đ”âđ«
Layla Anna
January 9, 2026 AT 21:00My cousin was on Jardiance and got really sick last year and the ER just sent her home because her sugar was 120... she ended up in ICU for 5 days đ I told her to always carry ketone strips now and she does. Everyone needs to know this. It's not just a diabetes thing-it's a life thing. â€ïž
Heather Josey
January 10, 2026 AT 10:08Thank you for this comprehensive and clinically accurate overview. The distinction between euglycemic DKA and classic DKA is critically underappreciated in primary care and emergency settings. I urge all clinicians to incorporate routine serum ketone screening for patients on SGLT2 inhibitors presenting with nonspecific symptoms. Early intervention saves lives.
Donna Peplinskie
January 12, 2026 AT 03:56Wow, this is so important-Iâve been telling my patients for years to check ketones even if their glucose is âfine,â but most of them donât even know what ketones are! I just ordered 20 blood ketone meters for my clinic. Letâs make sure no one gets sent home thinking theyâre okay because their sugar is ânormal.â Weâve got to protect each other, yâall.
Olukayode Oguntulu
January 13, 2026 AT 05:19The ontological dissonance inherent in the pharmacological paradigm of SGLT2 inhibition reveals a deeper epistemological failure in contemporary metabolic medicine. The reductionist reliance on glycemic metrics as a proxy for metabolic safety is a hermeneutic fallacy-a semiotic misalignment between physiological reality and diagnostic orthodoxy. The ketoacidotic cascade, once unmasked, exposes the ideological hegemony of pharmaceutical corporatism over clinical episteme.
jaspreet sandhu
January 13, 2026 AT 20:37I don't know why people are making such a big deal about this. I've been on Farxiga for three years and I'm fine. My sugar is always normal. I don't check ketones. If you're getting sick, maybe you're just not eating right or you're lazy. This whole thing is overblown. People these days are too scared of everything. I know someone who got DKA once and he didn't even have an SGLT2 inhibitor. So it's not the drug, it's the person. Stop blaming the medicine and start blaming yourself.
Dusty Weeks
January 15, 2026 AT 20:07so like... i was on invokana and got super dizzy and threw up and my sugar was 110 so i just laid down... turns out i had edka?? i had no idea. now i carry ketone strips everywhere. if youâre on one of these drugs and you feel off⊠just test. please. i almost died đ
Sally Denham-Vaughan
January 17, 2026 AT 10:23My momâs on Jardiance and sheâs 72. I showed her this post and now she checks ketones every time she feels âoff.â She says she used to think ânormal sugar = no problemâ but now she knows better. Itâs crazy how much we donât know until it almost kills us. So glad this info is out there đȘ
Bill Medley
January 17, 2026 AT 18:49While the clinical presentation of euglycemic DKA is well-documented, the systemic failure in diagnostic protocols remains a critical gap in emergency medicine infrastructure. Standardized protocols must be implemented universally, with mandatory ketone testing for all SGLT2 inhibitor users presenting with gastrointestinal or fatigue-related symptoms.
Ann Romine
January 19, 2026 AT 12:11Iâve been a nurse for 18 years and I didnât know about this until last year. One patient, 52, type 2, on Farxiga, came in with abdominal pain and vomiting. Glucose was 130. We thought it was gastro. She coded two hours later. We didnât check ketones. I still think about her. Please, if youâre on one of these drugs, learn this. Share it. Donât wait until itâs too late.
Austin Mac-Anabraba
January 20, 2026 AT 04:44Letâs be clear: the pharmaceutical industry engineered this crisis. SGLT2 inhibitors were approved based on surrogate endpoints-weight loss, HbA1c reduction-while ignoring the fundamental metabolic disruption they induce. The fact that ketone production is uncoupled from hyperglycemia is not an accident; itâs a design flaw masked as innovation. The FDAâs warning is a performative gesture. Real reform requires revoking these approvals and holding executives accountable.
Alex Warden
January 21, 2026 AT 21:20Why do Americans always blame the drug? We got better healthcare in Russia. Back home, if you got sick with sugar problems, they just gave you insulin and told you to eat rice. No ketone tests. No fancy machines. Just medicine. Now everyone here is paranoid about every little thing. You donât need to test ketones. Just donât take the drug if youâre not sure. Simple.