Why Low-Carb Diets and SGLT2 Inhibitors Are a Harmful Mixture

SGLT2 inhibitors are widespread diabetes drugs because of their means to decrease blood glucose ranges, with a really low threat of hypoglycemia. These medicine don’t simply assist take away extra glucose out of your bloodstream — additionally they enhance and defend kidney operate, lower the danger of coronary heart failure, and assist with weight reduction.

Whereas these advantages can have a big effect in your diabetes administration and long-term well being, SGLT2s even have a harmful facet impact that many individuals are unaware of. These medicine can carry an unacceptably excessive threat of diabetic ketoacidosis (DKA) for individuals who observe a strict low-carb or ketogenic food regimen.

How SGLT2 Inhibitors Work

In a nutshell, SGLT2 inhibitors forestall your kidneys from absorbing as a lot glucose out of your meals, stopping that sugar from getting into your bloodstream. As a substitute, that sugar is excreted by means of your urine. For a lot of, this leads to an instantaneous lower in blood sugar ranges and sometimes some weight reduction.

SGLT2s embody empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana), bexagliflozin (Branzavvy), and ertugliflozin (Steglatro). All manufacturers are capsules taken orally as soon as a day. 

Probably the most broadly recognized facet impact is dehydration. This impact is comparatively easy: On account of elevated urination, it’s possible you’ll be very thirsty and must drink quite a lot of water each day. In uncommon instances, dehydration may be extreme and harmful. Consuming sufficient water each single day is a essential a part of taking these drugs.

Different unintended effects of SGTL2s embody an elevated threat of yeast infections for ladies (as a result of glucose in your urine feeds the expansion of micro organism) and males (balanitis). There have additionally been uncommon experiences of necrotizing genital infections.

Dangerous Enterprise: Low-Carb Diets & SGLT2s

Low-carb diets naturally enhance your physique’s manufacturing of ketones — and that may be an excellent factor when you’re attempting to shed weight. If you’re consuming only a few carbohydrates, your physique burns fats extra shortly for gasoline, utilizing the ensuing ketones for vitality. 

In small quantities, ketones are protected and regular. Most individuals, with or with out diabetes, produce small quantities of ketones within the fasting state (like earlier than consuming breakfast). However very giant quantities of ketones can result in DKA, a harmful and doubtlessly even lethal situation.

Diabetic ketoacidosis (DKA) happens when an absence of insulin causes your blood to grow to be acidic. The physique’s cells can’t survive below acidic circumstances. When mixed with dehydration, this course of accelerates into a toxic cocktail that undermines the center, impairs the mind, and may result in loss of life in days.

In folks with diabetes, an ultra-low-carb food regimen (fewer than 50 grams per day) is normally protected — till you add one other part that may trigger the manufacturing of ketones to spiral uncontrolled. That’s precisely what SGLT2 inhibitors can do.

On their very own, SGLT2s don’t trigger DKA. As a substitute, they create a really perfect setting for the manufacturing of ketones when mixed with one other ketone-inducing issue, like a low-carb food regimen, dehydration, acute sickness, pump failures, fasting, or skipping insulin doses.

Simply one in all these extra components can drive your ketone manufacturing into overdrive, sending you into DKA. And in contrast to the DKA that most individuals with diabetes are in all probability conversant in, this may even happen when blood sugar ranges stay at a wholesome stage.

“A low-carb food regimen will increase the danger of DKA as a result of when a affected person consumes a low-carb food regimen, their complete each day dose (TDD) of insulin is decreased,” explains Kelsey Hutter MS, RD, CDCES, LD/N, who’s additionally lived with sort 1 diabetes (T1D) for 15 years. Although it’s normally thought-about wholesome to scale back your insulin necessities, when persons are utilizing a low-carb food regimen and SGLT2s on the identical time, they’ll find yourself utilizing much less insulin than they really want, even at wholesome blood sugar ranges.

SGLT2s considerably scale back how a lot glucose your physique absorbs out of your meals by passing the glucose out by means of your urine. On prime of all of it, you’re peeing considerably extra, which implies you’re continually on the sting of dehydration. Dehydration additionally contributes to the manufacturing of ketones. Hutter provides that SGLT2s enhance your physique’s use of physique fats for gasoline. This additional contributes to ketone manufacturing. 

SGLT2s & DKA in Type 2 Diabetes

Whereas DKA isn’t usually related to sort 2 diabetes (T2D), it’s changing into extra widespread — particularly in folks taking SGLT2s.

One specific research shares the small print of a 58-year-old man with sort 2 diabetes (T2D) and hypertension. This man was prescribed an SGLT2 inhibitor as a part of his remedy plan. He was not taking insulin.

“[He] was introduced in by ambulance and admitted to the intensive care unit for weak point, lethargy, and altered psychological standing,” explains the research.

They decided his blood strain was very excessive and he was in extreme DKA. 

The person’s blood work confirmed an A1C of 6.7 p.c however a blood glucose stage of 373 mg/dL on the time of admission. Whereas he’d been taking an SGLT2 treatment for a while, the one change he’d made up to now month earlier than this episode of DKA was beginning a ketogenic food regimen. 

“Our case demonstrates an instance wherein the usage of SGLT2 inhibitors with adherence to a ketogenic food regimen and intermittent fasting can result in DKA,” explains the research. 

The medical doctors additionally concluded that his blood glucose ranges and his pH ranges point out that his blood glucose ranges had been typically tightly managed. This unfortunate man should have thought that he was doing the whole lot proper.

“The distinctive presentation of DKA induced by SGLT2 inhibitors makes its prognosis difficult, particularly when all different precipitating components are dominated out. Moreover, upon evaluate of his different [diabetes] drugs, none are related to DKA making them as much less seemingly the reason for his presentation. On this case, investigating the affected person’s historical past together with his current change in food regimen revealed a major wrongdoer for his presentation.”

SGLT2s & Type 1 diabetes

SGLT2 inhibitors are solely FDA-approved for the remedy of sort 2 diabetes, however there has at all times been nice curiosity in utilizing them for sort 1, too. Research recommend that sufferers with T1D can take pleasure in the identical advantages, reminiscent of improved glucose ranges, modest weight reduction, and improved long-term kidney well being:

“Medical trials of SGLT2 inhibitors added to intensified insulin remedy in adults with T1D have proven reasonable reductions in A1C, glycemic variability, TDD of insulin, blood strain, and physique weight and elevated time in vary with out enhance in hypoglycemia,” explains Hutter.

Nevertheless, being insulin-dependent, folks with T1D face an particularly excessive threat of DKA when taking these drugs. Consequently, SGLT2s are solely not often prescribed off-label to folks with T1D.

“I presently work with two endocrinologists and one superior follow supplier,” explains Hutter. “Considered one of our endocrinologists will prescribe SGLT2s on a uncommon event to sufferers with T1D.  She’s going to prescribe to sufferers which are overweight and have a excessive TDD of insulin. Our endo does advise in opposition to consuming a low-carb food regimen and warns them of the DKA dangers.”   

Hutter provides that many endocrinologists will solely prescribe SGLT2s in T1D if a affected person has been recognized with coronary heart illness or kidney illness. 

The rising consensus for T1D is solely that the danger of DKA with SGLT2s is just too dangerous.

“In my skilled opinion, I really feel there may be not sufficient analysis to conclude that sort 1s can safely take SGLT2s,” says Hutter. “It’s nonetheless too quickly to make an evidence-based conclusion on the protection of SGLTs and T1D. There are different choices, together with GLP-1s, that will provide extra profit and fewer threat.”  

This threat has additionally precipitated well being authorities to proceed cautiously. The FDA and the EMA (European Medical Company) each thought-about approving SGLT2s for T1D, and each concluded the danger of DKA was too vital. Whereas each additionally acknowledged there are a number of advantages of those drugs for T1Ds, they felt that extra research had been needed to higher perceive the protection dangers. 

Carbohydrate consumption was listed as one in all many components that may contribute to DKA whereas taking an SGLT2. Different components embody excessive alcohol use, illicit medicine, viral or bacterial an infection, vomiting, insulin pump or infusion web site failure. 

Any affected person with sort 1 diabetes that takes an SGLT2 is in danger for DKA,” explains Hutter. 

Use With Warning

SGLT2 inhibitors provide great advantages for folks with sort 2 diabetes. However these highly effective drugs needs to be approached with data and warning. If in case you have sort 1 diabetes, or when you eat a low-carb or ketogenic food regimen, the analysis suggests taking an SGLT2 treatment may be harmful.


Chowdhury T et al. Fournier’s Gangrene: A Coexistence or Consanguinity of SGLT-2 Inhibitor Remedy. Cureus. August 2022.

Guirguis H et al. The Use of SGLT-2 Inhibitors Coupled With a Strict Low-Carbohydrate Weight loss program: A Set-Up for Inducing Extreme Diabetic Ketoacidosis. Medical Medication Insights: Case Stories. April 8, 2022.

Danne T et al. Worldwide Consensus on Threat Administration of Diabetic Ketoacidosis in Sufferers With Type 1 Diabetes Handled With Sodium–Glucose Cotransporter (SGLT) Inhibitors. Diabetes Care. February 6, 2019.

Maffei P et al. SGLT2 Inhibitors within the Administration of Type 1 Diabetes (T1D): An Replace on Present Proof and Suggestions. Diabetes, Metabolic Syndrome, and Weight problems. November 9, 2023.

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