The use and safety of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in hospital are controversial due to the risk of ketoacidosis. We aimed to describe rates of ketosis, ketoacidosis, and acidosis in patients with type 2 diabetes treated with in-hospital SGLT2i use. Single-centre retrospective cohort study of adult patients with type 2 diabetes admitted for >24 h. Rates of ketone testing, ketone levels, ketosis precipitants, and ketoacidosis and acidosis frequency were determined from examination of electronic medical records. Outcomes were described relative to the first dose of SGLT2i in hospital. There were 1511 patients who received SGLT2i at any stage of admission; of these, 777 (51.4%) had ketone levels checked. Peak ketone levels after the first dose of SGLT2i were >1 mmol/L in 12.6% and >3 mmol/L in 2.8%. Eleven out of 12 patients with ketones >3 mmol/L post-SGLT2i had ketosis in the setting of a procedure or surgery, sepsis, reduced oral intake, or critical illness. No patient admitted with heart failure had a ketone level >2 mmol/L. Biochemical ketoacidosis occurred in 1.7% of SGLT2i users pre-first dose of SGLT2i and 0.7% after the first dose. Acidosis (irrespective of ketone levels) occurred in 16.8% before the first dose of SGLT2i and 5.5% after the first dose. Ketosis following inpatient SGLT2i administration was infrequent and generally occurred in the setting of known precipitants. These results suggest that, in hospitalized patients selected by clinicians to receive SGLT2i, clinically significant ketone accumulation is low in prevalence.
Gao et al. (2025) studied this question.