From the Guidelines
SGLT2 inhibitors can be used in type 1 diabetes as an adjunct to insulin therapy, but their use requires close medical supervision due to the increased risk of diabetic ketoacidosis (DKA). The most recent study, published in 2024 1, highlights the benefits of SGLT2 inhibitors in type 1 diabetes, including improvements in A1C, reduced body weight, and improved blood pressure. However, this study also notes an increased rate of DKA associated with SGLT2 inhibitor use.
To minimize risks, the following precautions should be taken:
- Careful patient selection, avoiding those with a history of DKA, eating disorders, or poor compliance
- Thorough education about DKA symptoms
- Regular ketone monitoring
- Temporary discontinuation during illness, surgery, or fasting
- Maintenance of adequate insulin dosing and hydration
- Gradual and modest insulin reduction, typically not exceeding 20% of total daily dose
The use of SGLT2 inhibitors in type 1 diabetes is not approved in most countries, but they can be considered as an off-label treatment option under close medical supervision. The benefits of SGLT2 inhibitors, including empagliflozin, dapagliflozin, and canagliflozin, should be weighed against the risks, particularly the increased risk of DKA.
Key considerations for SGLT2 inhibitor use in type 1 diabetes include:
- Monitoring for DKA symptoms
- Regular ketone monitoring
- Maintenance of adequate hydration
- Gradual insulin reduction
- Close medical supervision
It is essential to prioritize the patient's safety and well-being when considering SGLT2 inhibitor use in type 1 diabetes, and to carefully evaluate the benefits and risks of this treatment option. As noted in the 2023 study 1, the risks and benefits of adjunctive agents, including SGLT2 inhibitors, continue to be evaluated, with consensus statements providing guidance on patient selection and precautions.
From the FDA Drug Label
Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus INVOKANA is not indicated for glycemic control in patients with type 1 diabetes mellitus. In patients with type 1 diabetes mellitus, INVOKANA significantly increases the risk of diabetic ketoacidosis, a life-threatening event, beyond the background rate
The usage of SGLT2 inhibitors, such as canagliflozin, is not recommended for patients with type 1 diabetes mellitus due to the increased risk of diabetic ketoacidosis 2, 2, 2.
From the Research
Usage of SGLT2 Inhibitors in Diabetes Type 1
- SGLT2 inhibitors have been shown to improve glycemic control and decrease body weight without the risk of increased hypoglycemia and with a reduction in insulin dose in patients with type 1 diabetes (T1D) 3, 4, 5.
- The use of SGLT2 inhibitors as an adjunct therapy to insulin in T1D has been approved in Europe for patients with a body mass index (BMI) of ≥27 kg/m2, inadequately controlled with insulin 3, 6.
- However, the use of SGLT2 inhibitors in T1D is associated with an increased risk of diabetic ketoacidosis (DKA), a serious and life-threatening adverse event 3, 4, 5, 6.
- Studies have suggested that the risk of DKA is higher in patients with T1D treated with SGLT2 inhibitors such as sotagliflozin and empagliflozin, and that there may be a dose-response relationship 3, 4.
- Education and monitoring are crucial to mitigate the risk of DKA in patients with T1D treated with SGLT2 inhibitors 3, 4.
- The benefits and potential risks of SGLT2 inhibitors in the management of T1D should be considered in each individual case, and further studies are needed to determine the safety and efficacy of this therapy in T1D 3, 4, 6.
Key Findings
- Dapagliflozin and sotagliflozin are the only SGLT2 inhibitors approved for the treatment of T1D in Europe 3, 6.
- SGLT2 inhibitors have been shown to improve glycemic control, reduce body weight, and decrease insulin dosage in patients with T1D 3, 4, 5.
- The use of SGLT2 inhibitors in T1D is associated with an increased risk of DKA, and education and monitoring are crucial to mitigate this risk 3, 4, 5, 6.
Future Directions
- Further studies are needed to determine the safety and efficacy of SGLT2 inhibitors in the management of T1D 3, 4, 6.
- Additional research is needed to define the type of patient who can benefit most from SGLT2 inhibitors in T1D 6.
- Education and monitoring programs should be developed to mitigate the risk of DKA in patients with T1D treated with SGLT2 inhibitors 3, 4.