SGLT2 Inhibitors in Type 1 Diabetes: Understanding the Risks and Benefits

This article delves into the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with type 1 diabetes. While these medications have shown promise, they also come with potential risks. We will explore their benefits, dangers, and safer alternatives for optimal diabetes management.

The Early Popularity of SGLT2 Inhibitors

Initially, SGLT2 inhibitors gained favor among healthcare providers like the author due to positive patient feedback. Users reported several advantages, including:

• Reduced glycemic variability
• Weight loss
• Lower A1c levels
• Easier diabetes management

The Emergence of a New Issue

However, the author noticed a concerning trend. Over time, patients began developing diabetic ketoacidosis (DKA), an infrequent condition in their practice. This prompted a deeper investigation into the connection between SGLT2 inhibitors and DKA development.

Collaborative Research and Protocol Development

Upon collaborating with Dr. Irl Hirsch and publishing a case series, the authors identified a correlation between SGLT2 inhibitor use and an increased risk of DKA. This research led to the creation of a detailed protocol for off-label use of SGLT2 inhibitors.

The protocol emphasized regular ketone monitoring, education on DKA prevention, and quick actions to stop SGLT2 inhibitors if necessary. Patients enjoyed 24/7 access to the author for any concerns.

Effectiveness of the Protocol

The protocol proved effective for patients on multiple daily insulin injections, preventing DKA. However, challenges remained for those on insulin pumps and automated insulin delivery systems.

Insulin Pumps and the DKA Risk

The author explored combining injected basal insulin with pump systems as a potential solution to prevent DKA in pump users. Unfortunately, efforts were halted due to the COVID-19 pandemic.

Despite the pause, ongoing research into SGLT2 inhibitors highlights their non-glycemic benefits, particularly in heart failure and chronic kidney disease (CKD).

Alternative Treatments for Type 1 Diabetes

Considering these benefits, the author advocates for SGLT2 inhibitors’ use when potential risks are managed. However, safer alternatives exist, including:

• GLP-1 receptor agonists (e.g., liraglutide)
• Nonsteroidal selective mineralocorticoid receptor antagonists (e.g., finerenone)

These options do not cause DKA and may offer similar benefits without increased risk in type 1 diabetes patients.

The Role of Continuous Ketone Monitoring

Continuous ketone monitoring could provide real-time data to help prevent DKA. However, the author raises concerns about potential device failures and their impact on patient management.

One memorable patient incident involved a bride who experienced severe DKA the night before her wedding due to an insulin pump occlusion and sensor failure.

Challenges in Underserved Populations

Patients in underserved areas face significant access challenges, including limited availability of ketone test strips and hyperkalemia concerns with RAAS inhibitors.

For this population, GLP-1 receptor agonists offer a safer alternative, providing non-glycemic benefits without DKA risk. Additionally, liraglutide, a generic option, might be suitable for overweight or obese patients with type 1 diabetes.

Conclusion

The journey with SGLT2 inhibitors in type 1 diabetes has revealed both benefits and risks. While these medications can offer significant advantages, alternative treatments exist for safer management, especially in vulnerable populations.

Continued research and innovation will help healthcare providers better navigate these complexities and provide the best possible care for their patients.

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