Euglycemic Ketoacidosis in Fasting Pediatric Heart Failure Patients Prescribed Dapagliflozin

Introduction: Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor (SGLT2i), has shown benefit in the treatment of pediatric heart failure (HF).1 In adults, SGLT2i have been associated with euglycemic ketoacidosis, but this risk has not been well studied in pediatrics.2 Pediatric HF patients are likely to undergo procedures that require no enteral intake (NPO), during which they may be initiated on dextrose fluids. This study aims to assess if dextrose fluids are protective against acidosis in pediatric HF patients prescribed dapagliflozin during NPO restriction.


Methods: This is a retrospective study of acidosis occurrence during NPO time in pediatric HF patients prescribed dapagliflozin. Inpatient encounters from 2022 to 2025 were screened. Inclusion criteria were diagnosis of HF, an order for dapagliflozin, and an occurrence of NPO time. Each encounter was categorized into one of two groups, those who received dextrose fluids during NPO time and those who did not. The primary outcome was occurrence of acidosis, which was analyzed using Fisher’s exact test.


Results: Thirty-one encounters from 23 patients were included. The study group had a median age of 10 years (IQR: 2-16) and weight of 30.6 kilograms (IQR: 13.3-59.9). The median duration of NPO time was shorter in those not receiving fluids (14.1 vs 20 hours). Dapagliflozin was held appropriately more often in those not receiving fluids (46% vs 36%). Acidosis developed in 5 encounters (5.8%) in the fluid group and 3 (6.2%) in those not receiving fluids (p=1).


Conclusions: Between those who received dextrose fluids and those that did not during NPO time, no difference was found in occurrence of acidosis. This study suggests that dextrose fluids do not have a significant effect on occurrence of acidosis. However, it is limited in assessing true incidence of ketoacidosis, the primary adverse event seen with this medication class, due to the lack of urine ketone collection. A direct correlation between dapagliflozin use and acidosis cannot be made from these results due to confounding causes of acidosis in critically ill patients. Further prospective studies are needed of all patients taking dapagliflozin while on dextrose fluids during NPO time, including routine monitoring for ketoacidosis.