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AACE/ACE position statement: SGLT2 inhibitors do not raise the background risk of DKA in type 2 diabetes

Following safety alerts from the US Food and Drug Administration and the European Medicines Agency that sodium–glucose cotransporter 2 (SGLT2) inhibitors may increase the risk of diabetic ketoacidosis (DKA) in people with type 2 diabetes, the American Association of Clinical Endocrinologists (AACE) and American College Of Endocrinology (ACE) have issued a joint position statement on the matter.

Based on a review of more than 80 cases in the literature, the AACE/ACE concluded that there is no definitive evidence to suggest that DKA occurs more frequently in type 2 diabetes now than it did before the advent of SGLT2 inhibitors. The majority of cases in fact occurred in people with insulin-deficient diabetes, including type 1 diabetes and latent autoimmune diabetes in adults (LADA). Furthermore, many cases reported in type 2 diabetes were in fact cases of ketosis, which is not necessarily harmful, rather than DKA.

However, whether in type 2 or other forms of diabetes, almost all cases of DKA were precipitated by metabolically stressful events, such as surgery, extensive exercise, myocardial infarction, stroke, severe infections, prolonged fasting, and other stressful physical and medical conditions. Therefore, the AACE/ACE recommend discontinuing SGLT2 inhibitors at least 24 hours prior to elective surgery, planned invasive procedures, or anticipated severe stressful physical activity such as running a marathon. They also recommend that people taking SGLT2 inhibitors should avoid excess alcohol intake and very-low-carbohydrate or ketogenic diets.

The statement can be read in full here.

Further information on DKA and SGLT2 inhibitors can be found in a new statement from the Primary Care Diabetes Society in the next issue of Diabetes & Primary Care.

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