SGLT2i Type 1 Diabetes DKA Risk — ESENeph MCQ

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ModerateDiabetic Kidney DiseaseSGLT2i Type 1 Diabetes DKA RiskESENeph

A 24-year-old woman with type 1 diabetes and CKD G2 (eGFR 85 mL/min/1.73m2, uACR 18 mg/mmol) is on an insulin pump. Her HbA1c is 58 mmol/mol. She has been reading about SGLT2 inhibitors for kidney protection. What is the key risk that limits SGLT2i use in type 1 diabetes despite their renal benefits?

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Correct answer: C — Diabetic ketoacidosis

SGLT2 inhibitors are NOT licensed for type 1 diabetes due to the significantly increased risk of euglycaemic diabetic ketoacidosis (euDKA). The mechanism involves insulin reduction (due to perceived improved glycaemic control), leading to uninhibited lipolysis and ketogenesis. Euglycaemic DKA is particularly dangerous because normal glucose levels delay recognition. While SGLT2i demonstrate clear renal benefits in T2DM and non-diabetic CKD, their use in T1DM remains off-label and generally not recommended. EMPA-KIDNEY and DAPA-CKD enrolled predominantly non-diabetic or T2DM patients. The MHRA and EMA have issued specific warnings against SGLT2i use in T1DM.

Reference: MHRA 2020 – SGLT2i DKA Safety Warning; EMA 2019 – SGLT2i T1DM Restriction