Sodium-glucose Co-transporter-2 Inhibitors in Type 1 Diabetes—a Dangerous Ally

T here is an unmet need for adjunctive non-insulin-based therapies in type 1 diabetes (T1D). Weight gain, recurrent hypoglycemia and suboptimal glycemic control remain significant challenges. Sodium-glucose co-transporter-2 (SGLT2) inhibitors and dual inhibitors of sodium-glucose co-transporter-1 (SGLT1) and SGLT2 may have a potential role as an add-on therapy to insulin. The benefits include improved glycemic control, weight reduction, and reduced insulin dose requirement. However, the risk of diabetic ketoacidosis with SGLT2 inhibitors is significant and the diagnosis may be delayed due to absence of significant hyperglycemia. At present, SGLT2 inhibitors are not approved for use in T1D, and the risks should be discussed at length with the patient. We propose strategies to minimize the risk of diabetic ketoacidosis associated with off-label use of SGLT2 inhibitors in T1D.