Type 1 and SGLT-2 Inhibitor? | QoW Rationale

This question addressed the use of SGLT-2 Inhibitors in addition to insulin for MS, who is living with Type 1 Diabetes. MS is worried about weight gain and is on a low keto diet. It is safe for here to add an off-label medication?

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: MS has type 1 diabetes and is on a low carb diet to help her keep her weight on target. She has a BMI of 24.3. MS has a friend with type 1 who is taking an SGLT-2 in addition to insulin to help with weight management. MS wants to know if she could add on an SGLT-2 to her insulin treatment plan. 

What is the Diabetes Specialist’s best response?

Answer Choices:

  1. We don’t recommend adding on an SGLT-2 for people with type 1 on a low carb diet.
  2. Your BMI of 24.3 is right on target.
  3. I’m sorry, but oral medications don’t work for people with type 1 diabetes.
  4. Do you think you might be struggling with disordered eating?

As shown above, the most common choice was option 1, the second most common answer was option 2, then option 4, and finally option 3.

Medication Considerations

If you are thinking about taking a certification exam, this practice test question will set you up for success. The test writers will include warnings about medications and ask you to choose the best response. Your job is to weed through the particulars, pluck out the most important elements, eliminate at least two false answers to improve your odds of success to 50/50.

Answer 1 is correct! “We don’t recommend adding on an SGLT-2 for people with type 1 on a low carb diet.” Even though SGLT-2’s are sometimes prescribed to people with type 1 diabetes (in addition to insulin), they are not FDA approved in type 1 and are considered “off-label.” SGLT-2 also contains a warning of an increased risk of ketoacidosis. This risk is especially important to consider in type 1 diabetes, since people with type 1 using an SGLT-2 Inhibitor may decrease their daily insulin dose and increase the risk of ketoacidosis.

This risk might be exacerbated by a low carbohydrate diet. As outlined in the ADA Standard 5, “This [low carbohydrate] eating pattern is not recommended at this time for women who are pregnant or lactating, people with or at risk for disordered eating, or people who have renal disease, and it should be used with caution in patients taking sodium-glucose cotransporter 2 inhibitors due to the potential risk of ketoacidosis.”

Answer 2 is incorrect! “Your BMI of 24.3 is right on target.” This is a juicy answer because it is true. The BMI is below 25, but it does not address the key intent of the question.

Answer 3 is incorrect. “I’m sorry, but oral medications don’t work for people with type 1 diabetes.” This is tricky. No oral medications are FDA approved for type 1 diabetes, but some are prescribed (metformin, SGLT-2s) by diabetes providers in addition to insulin. Still not the best answer.

Finally, Answer 4 is incorrect. “Do you think you might be struggling with disordered eating?” Another tempting answer, but MS isn’t exhibiting any signs of under-eating or under-dosing insulin or disordered eating.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

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