Current practices of SGLT2 inhibitor use and ketone monitoring in intensive care units: A multicentre observational study

Objective: Sodium-glucose co-transporter-2 (SGLT2) inhibitors offer benefits for patients with chronic kidney disease, heart failure, and type 2 diabetes mellitus (with cardiovascular risk factors or atherosclerotic cardiovascular disease) but concerns exist regarding euglycaemic diabetic ketoacidosis (EDKA) during acute illness and surgery. We evaluated SGLT2 inhibitor use, discontinuation patterns, and blood ketone monitoring in intensive care units (ICUs). Design: Prospective, multicentre, cross-sectional point prevalence study as part of The George Institute for Global Health and Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program. Setting: Fifty-two ICUs in Australia and New Zealand. Participants: Critically ill adult patients in ICUs on the study day. Main outcome measures: Number of patients receiving an SGLT2 inhibitor at ICU admission, their management, serum ketone levels, and ketoacidosis monitoring procedures. Results: Among 786 patients, 54 (6.9 %) were prescribed SGLT2 inhibitors prior to hospital admission, mostly for type 2 diabetes mellitus (75.9 %) or heart failure (18.5 %). Of these, 28 (51.9 %) had their SGLT2 inhibitor discontinued, primarily due to EDKA concerns. Only 17 (34.6 %) of the studied ICUs had documented ketone measurement policies, with 1 (1.9 %) including SGLT2 inhibitors as an indication for measurement. Of 114 patients with blood ketone measurements, 38 (33.0 %) had elevated levels, of whom 6 (5.2 %) met ketoacidosis criteria. Conclusions: Practice regarding discontinuation of SGLT2 inhibitors and ketone monitoring varies widely. With SGLT2 inhibitor use projected to increase, better understanding their risk-benefit profile in the ICU setting and more systematic approaches to ketone measurement are needed. Future research addressing these practice variations is essential.