Sodium Glucose Co-transporter 2 Inhibitor associated perioperative Diabetic Ketoacidosis.

Introduction: Sodium glucose co-transporter 2 (SGLT2) inhibitors were originally developed for the treatment of diabetes mellitus, however their approved use has expanded over recent years to include the treatment of heart failure and chronic kidney disease. This case series illustrates a spectrum of perioperative SGLT2 inhibitor related diabetic ketoacidosis (DKA), both euglycaemic and hyperglycaemic. We hope to highlight the challenges of both diagnosis and management of this condition. Cases: Case 1: Euglycaemic DKA in a 54-year-old post-emergency laparotomy, which recurred following resumption of her SGLT2 inhibitor. Case 2: Euglycaemic DKA in an 82-year-old post-emergency laparotomy. Case 3: Hypergylcaemic DKA in a 52-year-old patient who underwent arthroscopic shoulder surgery as a day case. Case 4: Euglycaemic DKA in a 78-year-old post-emergency lower limb revascularisation. Results: These cases highlight that the use of SLGT2 inhibitors carries the risk of perioperative DKA which can be difficult to diagnose and requires prompt management. Discussion: As the indications for the use of these medications expand, we must maintain a high clinical suspicion for DKA with their perioperative use.