Blood Glucose 8.9: Could This Still Be DKA?

The SGLT2 warning care-home staff must not miss

A care-home resident taking dapagliflozin becomes nauseated, complains of abdominal pain and starts breathing more deeply than usual.

Their blood glucose is 8.9 mmol/L.

A staff member says:

“His glucose is not very high, so it cannot be diabetic ketoacidosis.”

That conclusion could delay emergency treatment.

The 30-second answer

Yes—DKA can occur when the blood glucose result is normal-looking or only moderately raised, particularly in someone taking an SGLT2 inhibitor.

This is sometimes called euglycaemic DKA.

If the person has vomiting, abdominal pain, deep breathing, unusual drowsiness, confusion or serious deterioration:

Treat the symptoms as potentially significant.
Check whether they take an SGLT2 inhibitor.
Escalate urgently and mention the medicine by name.
Do not use the glucose result alone to rule out DKA.

The glucose may look reassuring. The person may not be safe.

Why can DKA be missed?

Diabetic ketoacidosis develops when there is insufficient effective insulin and harmful ketones accumulate, making the blood acidic. It is a medical emergency requiring hospital treatment.

DKA is commonly associated with very high blood glucose. However, the Medicines and Healthcare products Regulatory Agency warns that people taking SGLT2 inhibitors can develop DKA when glucose is only moderately elevated or near normal.

Medicines in this group include:

Dapagliflozin
Empagliflozin
Canagliflozin
Ertugliflozin

The generic name usually ends in “-gliflozin.” It may also be contained within a combination product, so staff must check the full medication record rather than relying on memory.

The risk is rare, but the consequences can be life-threatening. Illness, infection, vomiting, dehydration, reduced food intake, surgery and sudden insulin reduction can increase the risk.

What might care-home staff notice?

The resident may not say, “I think I have DKA.” Staff are more likely to notice a change in behaviour, breathing, eating or general condition.

Warning signs can include:

Nausea or vomiting.
Abdominal pain.
Deep or unusually fast breathing.
Unexpected tiredness or drowsiness.
New confusion or reduced responsiveness.
Dehydration or difficulty keeping fluids down.
Rapid deterioration without a clear explanation.
A fruity or pear-drop smell on the breath—although this may be absent.

Do not wait for every symptom to appear. Do not wait for a very high glucose reading.

What should staff do?

1. Look at the person—not only the glucose result

Assess the resident using their current care plan and your organisation’s deterioration pathway. Obtain observations within your role, but do not allow repeated checks to delay urgent help.

Call 999 when the person has symptoms suggesting DKA and is seriously unwell, particularly with deep breathing, marked drowsiness, confusion, reduced responsiveness or rapid deterioration.

For an unwell but apparently stable person, obtain urgent clinical advice through the appropriate GP, diabetes team or NHS 111 pathway.

2. Name the medicine and the concern

Do not report only:

“Resident has diabetes and feels unwell.”

A clearer escalation is:

“Mr Khan takes dapagliflozin. He has vomited twice, reports abdominal pain and is breathing more deeply than usual. His glucose is 8.9 mmol/L. I am concerned about possible SGLT2-associated DKA despite the glucose result.”

This wording tells the clinician why the apparently reassuring glucose must not end the assessment.

3. Follow the person’s ketone-testing plan

Where blood-ketone testing is included in the resident’s plan, staff are trained and appropriate equipment is available, follow that plan.

Blood-ketone measurement is preferred to urine testing in this situation because SGLT2 inhibitors can make urine-ketone results less reliable.

A normal glucose reading, an unavailable ketone test or an uncertain result must not delay emergency escalation when concerning symptoms are present.

4. Handle medicines safely

During acute illness, an SGLT2 inhibitor may need to be temporarily withheld. However, care-home staff must follow the resident’s authorised sick-day plan, local medicines procedure and urgent clinical or pharmacy advice.

Do not independently redesign the medication plan.

Never stop insulin simply because the person is not eating. Insulin omission can increase the risk of DKA. Any dose adjustment requires the person’s agreed plan or appropriate clinical direction.

Four dangerous responses

Avoid these mistakes:

“The glucose is below 10, so DKA is impossible.”
“Let us encourage fluids and review tomorrow.”
“The urine ketone result is negative, so there is no concern.”
“They are not eating, so we should omit all diabetes medicines, including insulin.”

Each response relies on an assumption instead of the person’s symptoms, medicines and clinical condition.

A care-home example

Mrs Evans takes empagliflozin. During the afternoon, she refuses lunch, vomits and becomes unusually sleepy. Her blood glucose is 9.4 mmol/L.

The care worker reports the change immediately. The nurse reviews the medication record, recognises the SGLT2 inhibitor and assesses Mrs Evans. Her breathing is deeper than usual and she is becoming increasingly difficult to engage.

The nurse calls 999 and clearly states:

“Possible SGLT2-associated diabetic ketoacidosis despite a glucose of 9.4.”

The important action is not diagnosing DKA in the care home. It is recognising that the glucose result does not safely exclude it and obtaining emergency assessment.

A record that supports safe follow-up

A useful entry would state:

“At 14:20, Mrs Evans vomited after refusing lunch and appeared unusually drowsy. Respirations were deeper than her recorded baseline. Blood glucose 9.4 mmol/L. Medication record confirmed empagliflozin. Possible SGLT2-associated DKA considered. Nurse informed immediately; 999 called at 14:28. Current medicines and observations prepared for ambulance handover.”

Record what was observed, when it changed, the medicine involved, the action taken and the outcome. Do not document a diagnosis that has not been clinically established.

Save this five-point check

When a resident taking a “-gliflozin” medicine becomes acutely unwell, ask:

Are they vomiting or unable to eat and drink normally?
Do they have abdominal pain, deep breathing, drowsiness or confusion?
Could the glucose result be creating false reassurance?
Have I named the SGLT2 inhibitor during escalation?
Am I following the authorised sick-day and medication plan?

The question for your next handover

If a resident taking dapagliflozin started vomiting tonight, would every staff member know that a normal-looking glucose result does not exclude DKA?

If the answer is uncertain, this is not merely a knowledge gap. It is a patient-safety risk.