Case series / case reportindependent cross-checkabstract checked I-ODD-128 standard review

Ketoacidosis with low blood sugar on SGLT2 drugs: rare published cases, often after fasting

Ketoacidosis at Hypoglycemic and Low Glucose Levels Associated with SGLT2 Inhibitor Use: A Descriptive Systematic Review of Published Cases.

Overview

Itagaki H et al.. J Clin Med 2026 · PMID 42882058 · DOI 10.3390/jcm15197595

15 cases, median glucose 68 mg/dL; fasting or poor intake in 11 of 15.

Does the study support the specific claim? Yes · Methodological quality: very low

Study explained simply

What did the researchers want to find out?: Describe ketoacidosis at low glucose in SGLT2 inhibitor users.
How was the study done?: Systematic review of case reports.
How many people, animals or samples were studied?: 15 cases.
What was actually found?: Severe acidosis despite low sugar; fasting the main trigger.
How large was the observed effect?: Not applicable.
What do the results mean in everyday life?: On these drugs, a normal or low sugar reading does not rule out a dangerous acid build-up, especially when fasting.
What are the study's limitations?: Very small, case-based.
What does it say about Elawady's specific claim?: Supports the 'low glucose' part.
Do the results apply to Germany and Europe?: High.
What can explicitly not be concluded from this study?: How often it happens.

Authors: Itagaki H et al.
Journal: J Clin Med
Year: 2026
Identifier: PMID 42882058 DOI 10.3390/jcm15197595
Verification: verified – PubMed efetch 2026-10-26; Crossref works API 2026-10-26
Retracted: no
Corrections: none
Extent checked: abstract only
Conflicts of interest and funding: Not stated in abstract.

What is the clinical picture of ketoacidosis with blood glucose below 100 mg/dL in SGLT2 inhibitor users?

Study design: Case series / case report – Descriptive systematic review of published case reports and case series (not registered)
Population: Published cases of ketoacidosis with glucose <100 mg/dL during SGLT2 inhibitor use
Country: International (published cases)
Period: Searches to 25 June 2026
Sample size: 15 cases
Inclusion and exclusion criteria: Peer-reviewed case reports/series with documented glucose <100 mg/dL at or near diagnosis

Exposure / intervention: SGLT2 inhibitors (ongoing or stopped within about 2 weeks)
Comparator: None
Endpoints: Clinical phenotype, precipitants, biochemistry
Statistical methods: Descriptive; Spearman correlation

Results: 15 cases (median age 61; 6 without diabetes; 6 treated for heart failure). Median glucose 68 mg/dL (10/15 <70). Median pH 7.17, anion gap 19.9, beta-hydroxybutyrate 5.0 mmol/L. Fasting or poor oral intake was the commonest precipitant (11/15). One death (aspiration).
Absolute risks: Not estimable (case reports).
Authors' conclusion: Ketoacidosis can occur at hypoglycaemic and low glucose levels in SGLT2 inhibitor users; the design cannot establish incidence, risk or causality (very low certainty); clinicians should consider ketoacidosis even without hyperglycaemia.

Descriptive only; shows the phenomenon exists, not how often.

Documents the 'low blood glucose' variant named in the claim; fasting was the commonest trigger, which is directly relevant to fasting-based diets.

None; the rarity of the low-glucose form is the main limitation.

High.

Confirms that the low-glucose presentation exists, rarely.

Multidimensional assessment
Multidimensional assessment
Authenticity of the source	verified
Methodological quality	very low
Risk of bias	high
Precision of results	not applicable
Directness	direct
Reproducibility	unknown
Consistency with the overall evidence	consistent
Regional transferability	high
Adequacy of the interpretation (by the archive)	not applicable

Incidence.