Efficacy and Safety of Dapagliflozin in Patients With Inadequately Controlled Type 1 Diabetes: The DEPICT-1 52-Week Study

Sodium-glucose cotransporter 2 inhibitor-associated diabetic ketoacidosis in patients with type 1 diabetes: Metabolic imbalance as an underlying mechanism

For type 1 diabetes patients with inadequate glycemic control, one treatment option is to increase the insulin dose (scenario 1), which should not give rise to a “metabolic imbalance.” A second option is additional treatment with a sodium–glucose cotransporter 2 inhibitor, which might lead to a “metabolic imbalance” (scenario 2). A reduction in insulin dose in addition to administration of a sodium–glucose cotransporter 2 inhibitor might further increase the “metabolic imbalance” (scenario 3).

Reversal of Ketosis in Type 1 Diabetes Is Not Adversely Affected by SGLT2 Inhibitor Therapy

OBJECTIVE

We have shown that "euglycemic DKA" in patients with type 1 diabetes receiving a sodium-glucose cotransporter 2-inhibitor (SGLT2i) is due to normal increases in rates of ketogenesis but blunted increases in plasma glucose levels. In this analysis, we assessed whether rescue treatment of early ketoacidosis with insulin is altered by SGLT2i use.

RESEARCH DESIGN AND METHODS

Participants received 0.2 U/kg of aspart insulin after two 6-h interruptions of basal insulin that increased beta-hydroxybutyrate (BHB) by 1.2 ± 0.7 mmol/L before and by 1.5 ± 0.2 mmol/L during canagliflozin treatment. BHB and free fatty acid (FFA) were monitored every 30 min for 120 min after receiving a 0.2 U/kg subcutaneous injection of aspart insulin.

RESULTS

Ten adults (23 ± 5 years) were studied. During the 120 min after rescue therapy with insulin, the reductions in BHB and FFA were nearly identical between the pre- and during canagliflozin treatment studies, respectively (-1.27 ± 0.76 and -1.13 ± 0.69, P = 0.671 for BHB and -0.50 ± 0.35 vs. -0.41 ± 0.41, P = 0.603 for FFA).

CONCLUSION

These data indicate that turning ketogenesis off, as well as on, does not appear to be affected by SGLT2i use.

Empagliflozin in type 1 diabetes

There is a clear unmet need in people living with type 1 diabetes (T1D). Although the quality of life of people with T1D has improved, issues like hypoglycemia, weight gain and variability in glucose profiles remain. In this review, the clinical efficacy and safety of empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor in T1D, is described based on a review of phase 2 and 3 studies to date. Empagliflozin and SGLT2 inhibitors, in general, are effective glucose-lowering drugs, which also work in people with T1D. Recent phase II and III studies, including the EASE trials for empagliflozin, showed a clear beneficial effect on HbA1c, body weight, glucose variability and total daily insulin use in people with T1D. No increase in hypoglycemia risk, in particular severe hypoglycemia, was observed, but genital infections were more prevalent. The use of SGLT2 inhibitors comes with a decrease in insulin doses, making individuals more prone to diabetic ketoacidosis (DKA). The uniqueness of the EASE program is that here, a very low dose of empagliflozin was used, with less, but still present, effects on metabolic outcomes, but interestingly a lower risk of DKA. Importantly, even in the higher doses of empagliflozin, it is clear that the overall risk for DKA remains low, most likely by educating patients and caretakers intensively on this subject. In conclusion, evidence is building on the potential of using empagliflozin, like other SGLT2 inhibitors, in T1D. However, to date, the use of empagliflozin is not approved in people with T1D. Clinicians will have to weigh the potential short- and long-term benefits of these adjunct therapies versus the potential acute side effects, in particular, the small but real risk of DKA in the individual T1D patient.

A Systematic Review and Meta-Analysis of Randomised Controlled Trials, Contrasting the Safety Profile between Sodium-Glucose Cotransporter-2 Inhibitors and Placebo in Type 1 Diabetes Mellitus Patients

<b><i>Background:</i></b> This study aims to contrast the side effects of treatment with sodium-glucose cotransporter-2 inhibitors (SGLT2i) and placebo in insulin-treated adult type 1 diabetes mellitus (T1DM) patients. <b><i>Methods:</i></b> Double-blinded randomized controlled trials that compare the above outcome were searched in electronic databases. Next, the risk of bias in eligible studies was assessed, and comparable outcomes were compared by a random-effects meta-analysis. <b><i>Results:</i></b> Seven eligible papers comprising about 3,900 participants were studied. All trials suffered from an unclear risk of detection bias and performance bias. In comparison with the placebo group, the risk of genital infection (RR = 3.22, <i>p</i> &#x3c; 0.001, 95% CI 2.31–4.49, <i>I</i>² = 0%) and diabetic ketoacidosis (RR = 2.66, <i>p</i> = 0.002, 95% CI 1.45–4.89, <i>I</i>² = 0%) was higher in the SGLT2i-treated group. <b><i>Conclusion:</i></b> SGLT2i treatment increased the risk of genital infection and diabetic ketoacidosis in adult insulin-treated T1DM patients.