What is euglycemic DKA and should I be worried?

Euglycemic diabetic ketoacidosis (DKA) is a rare but serious condition where ketoacidosis occurs even with normal or near-normal blood sugar levels. Because blood sugar is normal, it can be missed. Risk factors include fasting, surgery, illness, low carbohydrate diet, and excessive alcohol. Know the symptoms (nausea, vomiting, abdominal pain, shortness of breath) and seek emergency care if they develop.

How does canagliflozin protect the kidneys?

SGLT2 inhibitors reduce pressure inside the kidney's filtering units (glomeruli), which slows kidney disease progression. The CREDENCE trial showed canagliflozin significantly reduced the risk of kidney failure and cardiovascular death in patients with diabetic kidney disease.

Can canagliflozin cause low blood sugar on its own?

Canagliflozin has a low risk of hypoglycemia when used alone. However, when combined with insulin or sulfonylureas, low blood sugar risk increases — your insulin or sulfonylurea dose may need to be reduced when starting canagliflozin.

What to Expect When Starting Canagliflozin

Q: Will canagliflozin help me lose weight?

Yes, modestly. On average, patients lose 1-3 kg over the first several months due to caloric loss through urinary glucose excretion. Weight loss is not dramatic but is a real benefit on top of blood sugar control.

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Introduction

Canagliflozin (Invokana) is an SGLT2 inhibitor that lowers blood sugar by causing the kidneys to excrete excess glucose in the urine. It also offers cardiovascular and kidney-protective benefits in patients with type 2 diabetes. Blood sugar lowering effects begin quickly, within days of starting, while cardiovascular and kidney benefits accumulate over months to years.

Week-by-week timeline

Day 1-3

Initial Blood Sugar Effects

Canagliflozin begins lowering blood glucose within the first day by increasing urinary glucose excretion. You may notice increased urination and thirst as glucose is excreted. Genital moisture increases, raising infection risk — maintain good hygiene.

Week 1-2

Adjustment Period

Increased urination typically stabilizes. Genital yeast infections can occur within the first weeks, more commonly in women. Symptoms: itching, discharge, odor. UTI risk is also modestly elevated. Staying well-hydrated is important.

Week 2-4

Blood Sugar and Weight Effects

Fasting and post-meal blood glucose levels should be measurably lower. Canagliflozin also causes modest weight loss (1-3 kg on average) due to caloric loss through urinary glucose excretion. This is a real benefit, not just fluid shifts.

Month 1

Metabolic Monitoring

Your prescriber will check HbA1c, kidney function (eGFR, creatinine), and electrolytes. Canagliflozin is not recommended when eGFR is below 30 mL/min. Blood pressure may decrease modestly, which is beneficial but may require adjustment of antihypertensive medications.

Month 2-3

Long-Term Benefits

Clinical trials (CANVAS, CREDENCE) show that canagliflozin reduces cardiovascular events, hospitalizations for heart failure, and kidney disease progression in at-risk patients. These benefits accrue over months to years of consistent use.

When to call your doctor

Contact your healthcare provider if you experience:

Signs of diabetic ketoacidosis (DKA): nausea, vomiting, abdominal pain, fatigue, difficulty breathing, fruity-smelling breath — EVEN IF BLOOD SUGAR IS NORMAL (euglycemic DKA is a known risk)
Sudden decrease in urination, swelling, or rapid weight gain (kidney problems)
Signs of genital gangrene (Fournier gangrene — rare but serious): pain, tenderness, redness, or swelling in the genital or perineal area with fever
Signs of low blood sugar if also taking insulin or sulfonylurea: shakiness, sweating, confusion
Sudden bone pain or hip/thigh pain (increased fracture risk, particularly with canagliflozin 300 mg)
Signs of severe urinary tract infection: fever, back pain, chills

Tips for getting started

Take canagliflozin once daily in the morning, before your first meal. Maintain good genital hygiene and wear breathable cotton underwear to reduce yeast infection risk. If you develop a yeast infection, over-the-counter antifungals work — notify your prescriber. If you are going to have surgery, stop canagliflozin 3-4 days before (or longer if major surgery) to reduce DKA risk — inform your surgical team. Stay well hydrated. Monitor for hypoglycemia if you also take insulin or a sulfonylurea.

Frequently asked questions

More about Canagliflozin

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References

[Regulatory] FDA Label: Invokana (canagliflozin) Tablets https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/204042s035lbl.pdf Accessed 2026-03-01.
[Regulatory] NIH MedlinePlus: Canagliflozin https://medlineplus.gov/druginfo/meds/a613033.html Accessed 2026-03-01.
[Clinical] CANVAS Trial: Canagliflozin and Cardiovascular/Renal Events https://www.nejm.org/doi/10.1056/NEJMoa1611925 Accessed 2026-03-01.

Written and fact-checked by PrescriptionDrugs.org Editorial Team

Last updated: March 1, 2026