From the Guidelines
SGLT2 inhibitors may be used off-label as adjunctive therapy to insulin in select patients with type 1 diabetes, but their use requires careful patient selection, education, and monitoring due to the increased risk of diabetic ketoacidosis. The most recent and highest quality study, 1, provides guidance on the use of SGLT2 inhibitors in patients with type 1 diabetes, highlighting the importance of assessing underlying susceptibility to ketoacidosis, providing education on risks and prevention strategies, and prescribing home monitoring supplies for β-hydroxybutyrate. Key benefits of SGLT2 inhibitors in type 1 diabetes include improved glycemic control, reduced glucose variability, weight loss, and potential cardiovascular and renal protection, as noted in 1 and 1. However, the risk of diabetic ketoacidosis, particularly euglycemic ketoacidosis, must be carefully managed, as emphasized in 1 and 1. Typical starting doses for SGLT2 inhibitors in type 1 diabetes are lower than for type 2 diabetes, such as dapagliflozin 5mg daily, empagliflozin 10mg daily, or canagliflozin 100mg daily, and treatment should be temporarily discontinued during illness, surgery, or other stressors to prevent DKA. Regular monitoring of ketones is essential, especially when glucose levels are elevated, as recommended in 1. Overall, the use of SGLT2 inhibitors in type 1 diabetes requires a careful balance of benefits and risks, with a focus on minimizing the risk of diabetic ketoacidosis.
Some key points to consider when using SGLT2 inhibitors in type 1 diabetes include:
- Careful patient selection, including those with preserved C-peptide, good compliance, and no history of DKA
- Education on ketone monitoring and prevention strategies
- Regular monitoring of ketones, especially when glucose levels are elevated
- Temporary discontinuation of treatment during illness, surgery, or other stressors to prevent DKA
- Starting with lower doses, such as dapagliflozin 5mg daily, empagliflozin 10mg daily, or canagliflozin 100mg daily. It is essential to weigh the potential benefits of SGLT2 inhibitors against the risks and to closely monitor patients for signs of diabetic ketoacidosis, as noted in 1, 1, and 1.
From the FDA Drug Label
DAPAGLIFLOZIN TABLETS are not indicated for glycemic control in patients with type 1 diabetes mellitus. In patients with type 1 diabetes mellitus, dapagliflozin significantly increases the risk of diabetic ketoacidosis, a life-threatening event, beyond the background rate Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus
The role of Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors, such as dapagliflozin and canagliflozin, in the management of type 1 diabetes is limited due to the increased risk of diabetic ketoacidosis.
- The FDA drug labels for these medications explicitly state that they are not indicated for glycemic control in patients with type 1 diabetes mellitus 2, 3, 3.
- The use of SGLT2 inhibitors in patients with type 1 diabetes may increase the risk of ketoacidosis, which can be life-threatening.
- Therefore, SGLT2 inhibitors are not recommended for use in patients with type 1 diabetes mellitus.
From the Research
Role of SGLT2 Inhibitors in Type 1 Diabetes Management
The use of Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors in patients with type 1 diabetes has been explored in several studies 4, 5, 6, 7, 8. These inhibitors have shown potential in improving glycemic control, reducing body weight, and lowering the risk of cardiovascular events.
Benefits of SGLT2 Inhibitors
Some benefits of SGLT2 inhibitors in type 1 diabetes management include:
- Improved glycemic control without increasing the risk of hypoglycemia 4, 5
- Weight loss and reduced body mass index (BMI) 5, 7
- Reduced glycaemic variability and increased Time in Range (TIR) 7
- Potential nefro-cardiovascular protection 8
Risks and Side Effects
However, SGLT2 inhibitors also carry some risks and side effects, including:
- Increased risk of diabetic ketoacidosis (DKA) 5, 6, 7, 8
- Need for careful patient selection, education, and continuous ketone body monitoring 7
- Potential for increased risk of cardiovascular events and mortality 6
Current Evidence and Recommendations
Current evidence suggests that SGLT2 inhibitors may be beneficial in type 1 diabetes management, but their use should be approached with caution due to the increased risk of DKA 8. The European Medical Agency (EMA) has temporarily licensed the use of SGLT2 inhibitors as an adjunct to insulin therapy in adults with type 1 diabetes and a BMI of 27 kg/m2 or higher, but the US Food and Drug Administration (FDA) has expressed concerns about the safety of these agents 8. Further studies are needed to determine the safety and efficacy of SGLT2 inhibitors in type 1 diabetes management and to define the type of patient who can benefit most from these medications 8.
Key Considerations for Clinical Practice
Key considerations for clinical practice include: