SGLT2 inhibitors have become essential in the treatment of type 2 diabetes, effectively lowering blood sugar levels while also decreasing cardiovascular incidents and slowing the progression of kidney disease. Nevertheless, their application in type 1 diabetes (T1D) is complicated due to the elevated risk of diabetic ketoacidosis (DKA) they entail.

**Glycemic and Metabolic Effects**

Major studies, such as DEPICT-1 and 2 (dapagliflozin) and inTandem 1–3 (sotagliflozin), demonstrate that SGLT2 inhibitors can diminish HbA1c by 0.3–0.4%, reduce insulin requirements by 6–15%, encourage a weight loss of 2–3 kg, and lower glycemic variability in T1D. However, the incidence of DKA was significantly higher.

**Kidney Protection: Early Clues**

There is promise for kidney protection akin to the advantages observed in type 2 diabetes. Research indicates that dapagliflozin can decelerate the advancement of albuminuria and safeguard eGFR. While encouraging, these results need more validation. The SUGARNSALT study, set to conclude in 2028, is highly awaited for its findings related to kidney health and DKA prevention in T1D.

**Continuous Ketone Monitoring: A Safety Innovation**

To mitigate DKA risks, continuous ketone monitoring (CKM) is in development. CKMs offer real-time tracking of ketone levels, potentially facilitating timely interventions. Although extensive studies are still forthcoming, CKMs provide optimism for safer SGLT2 inhibitor usage in T1D, with FDA approvals expected in 2025 or 2026.

**Current Regulatory Status and Practical Use**

At present, SGLT2 inhibitors are not sanctioned by the FDA for T1D, and the ADA recommends against their utilization outside clinical research. Nevertheless, some endocrinologists prescribe them off-label for patients who are overweight, insulin-resistant, or displaying early kidney disease or elevated cardiovascular risks.

**Key Safety Principles if Used Off-Label**

Prescribing SGLT2 inhibitors in T1D should be approached with caution and involve:
– Initiating at lower doses
– Informing patients about ketone testing and guidelines for sick days
– Regular ketone monitoring
– Halting use during illnesses or fasting periods
– Avoiding use in specific high-risk individuals

**The Bottom Line**

Although SGLT2 inhibitors present possible advantages for T1D, especially concerning glycemic and kidney effects, the heightened DKA risk demands meticulous patient selection and monitoring. The introduction of CKMs could establish a vital safety measure, potentially transforming their usage landscape in the coming years. Until then, SGLT2 inhibitors should be confined to decisions made by specialists and not broadly prescribed by general practitioners, who should refer such prescriptions to endocrinology experts.