Dapagliflozin with insulin for patients with Type 1 Diabetes

This is a new guideline from NICE on using dapagliflozin in patients with Type 1 diabetes. It was published in Aug 19.

Key learning points for me:

  • There is a rise in the risk of ketoacidosis.
  • It needs stopping if there is a sustained fall in GFR to < 45.

The main concern with using dapagliflozin alongside insulin in patients with Type 1 diabetes (T1DM) is that there is an almost two-fold rise in the risk of diabetic ketoacidosis. However the absolute risk is not that high. Because of this, quite rigid restrictions have been placed on who is eligible.

Patients will be suitable if they have a BMI of at least 27 where an optimal insulin regime does not provide adequate glycaemic control if:

  • they are on insulin doses of 0.5u / kg / day and
  • have completed a structured educational course about diabetic ketoacidosis and
  • treatment is started and supervised by a specialist endocrinologist.

HbA1c should be checked at 6m and regularly thereafter. Dapagliflozin should be stopped if there isn't a sustained drop in HbA1c of 0.3% or more.

Dapagliflozin should not be started if the GFR is < 60 and should be stopped if there is a sustained drop in GFR to < 45.

Interestingly the benefits of adding dapagliflozin are only small and seem to wane over time. It is too early to know whether it will have any effect on lifespan.

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