Nausea, vomiting and abdominal pain. Patients will be breathing fast or there will be a smell of ketones and, generally, they always will be feeling unwell. Always check for capillary ketones, as ketoacidosis can occur with normal glucose levels in patients on SGLT2 inhibitors.
DKA on empagliflozin can be life-threatening even with normal glucose levels, so patients can present as very unwell and need ICU level care. However, patients may also have minimal symptoms if detected early, but still require acute admission for IV insulin and glucose infusions to prevent progression to severe DKA. The main advice to prevent DKA is not using empagliflozin in patients who are at high risk of DKA ie, do not use in patients on < 130 g of carbohydrate per day, those with a high alcohol intake, or those who are severely insulin-deficient eg, type 1 diabetes or end-stage type 2 diabetes. It is also important to emphasise sick day management including stopping empagliflozin at least 2 days before a surgical procedure (at least 4 days if bowel prep), staying well hydrated and getting their ketone levels checked if symptomatic.