In case you missed my first post on SGLT2s, you can check it out here for all the background info!

SGLT2s: They Cause Fewer Low Blood Sugars

Picking up where we left off on our discussion of SGLT2s: the reduction in insulin dose on SGLT2s also results in fewer lows. Because insulin causes lows, when you have less on board you will go low less.

This means that good candidates for this drug are not those just taking too much insulin, but those who are also already achieving target A1cs at the expense of lows.

For example, my A1c was 5.9% when I started on the drug but I was having lows to the 40s almost every day. When I started the drug I instantly noticed though that my blood sugars would stay much more stable, hanging out in the 80s-90s and staying there regardless of my activity or when I ate.

This is a proven effect of SGLT2 inhibitors - they reduce standard deviation in blood sugars, blunting the severity of both highs and lows. Think about it this way: less insulin means less rollercoaster, which is also why eating low carb makes blood sugar management easier.

SGLT2 Inhibitors Aren’t The Answer

But, just like a closed loop system, this does not mean that you can just pop a pill and achieve good results without paying attention.

In fact, not paying attention to an SGLT-2 inhibitor is really dangerous, and another reason why my endo has so few patients on them. Because you are using less insulin, the SGLT-2i means that you are inherently at increased risk for DKA.

In fact, there is an increased risk of going into DKA even though your blood sugar is normal.

This is because the drug is doing some of the heavy lifting, keeping your blood sugar down for you, so you don’t need as much insulin. But you also may not notice when “not as much” insulin becomes “not enough” insulin.

Things like dehydration, not eating, and illness can tip over into DKA quicker than they would otherwise, so to be on this drug you have to be on top of your game and able to realize why your blood sugars and body are doing what they are doing. You must also be able to do what’s necessary to address it.

Intimate knowledge of physiology helps, which is why my doctor lets me be on this drug. Even so, he gave me a ketone meter and told me to start checking if I ever felt weird, just in case!

SGLT2 Benefits, Risks, & Side Effects

Since being on my SGLT2 inhibitor, I can breathe easy at 9600ft! Okay, maybe not that easy, but I have noticed a difference in my ability to adapt to altitude. Why? Because SGLT2-is increase your hematocrit and, thus, the oxygen carrying capacity of your blood. But that’s not all - take a look at the rest of the awesome benefits to taking a SGLT2:

• Increased hematocrit!
• ~5% weight loss (insulin causes fat storage. Less insulin + peeing out sugar = weight loss. But of course you can still out-eat this effect). 
• Lowered blood pressure (weight loss + dehydration). 
• It’s renal-protective. 
• Reduced risk of cardiovascular disease (Most T1Ds are overweight, insulin resistant, and have some degree of the T2-style metabolic syndrome, which causes CVD).
• The lowered blood sugar aspect I mentioned before (in Part 1!). 

Of course, there are the risks (as with any drug):

• UTIs + yeast infections (more sugar in your GU tract, more risk. I’ve been on the drug for 2 years and never had an issue; my endocrinologist says the risk is highest in the first 6 months).
• Dehydration (while the frequent urination goes away, it’s because your body adapts to the new fluid balance).
• Some concern for decreased bone density but this is not well-supported by meta-analyses
• They’ve been linked to increased risk of amputations, but the risk is still low and if you take care of yourself (ie, keeping blood sugars in-range by checking often) you’ll be fine. 
• They are not FDA approved for use in T1D (yet) so you will have to pay out of pocket or get your doc to hook you up with a discount (🙋‍♀️). 
• And of course, the DKA stuff I talked about in earlier posts!

As a patient and a (99%) doctor, I wouldn’t recommend a SGLT2-i to just anybody.

But, I think that in the right person they can be a hugely beneficial adjunctive to type 1 diabetes (and, of course, type 2 diabetes) management. Talk to your doctor if you’re interested!