Diabetic Ketoacidosis After Sodium–Glucose Cotransporter Inhibitor Initiation Under Advanced Hybrid Closed-Loop Therapy in Type 1 Diabetes

Sodium–glucose cotransporter inhibitor (SGLTi) use is not uncommon in type 1 diabetes (T1D). Not much is known about possible risks or benefits when combining SGLTi with advanced hybrid closed-loop (aHCL). This report describes in detail the daily insulin dosing by the MiniMed™ 780G algorithm in a patient with T1D after SGLTi initiation leading to diabetic ketoacidosis (DKA). Within a few days after start of SGLTi, the aHCL algorithm reduced autobasal and autocorrection doses, whereas meal bolus insulin doses were reduced mainly due to frequent activation of the “safe meal bolus.” Taken together, there was a significant 49% reduction in total daily insulin dose after start of SGLTi, leading to insulin doses below the minimum needed to prevent ketone formation. Until more is known about the influence of SGLTi on aHCL algorithm functioning, we recommend caution with SGLTi use in people with T1D on aHCL systems to avoid increased DKA risk.