Over a span of several months, I helped care for three separate patients taking sodium-glucose cotransporter-2 (SGLT2) inhibitors for at least the past 2 years who presented to the ICU with euglycemic diabetic ketoacidosis **(**DKA) within a few weeks of initiating a keto diet.
These days, SGLT2 inhibitors are being prescribed so frequently, it sometimes feels like they’ve been added to the water supply. Yet, most of us can agree that they aren’t always safe, and several US Food and Drug Administration (FDA) warnings have been added or strengthened for [acute kidney injury], [urinary tract infection], and euglycemic DKA.
The FDA warning on euglycemic DKA focuses on pausing SGLT2 inhibitors for several days prior to surgery and asks patient to tell their healthcare professional about any of the following DKA risk factors prior to taking an SGLT2 inhibitor: eating less due to illness, a history of pancreatitis, or frequent or binge alcohol consumption. There is no mention of a keto diet. However, the mechanisms of action of SGLT2 inhibitors and that of a keto diet are synergistic in nature, propelling the body rapidly into a DKA. Unfortunately, most of us were not taught this about this drug class.
https://www.medscape.com/viewarticle/keto-diet-sglt2-inhibitors-may-contribute-diabetic-2025a10007z8
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Well what if you just add exogeneous ketones + SGLT2 inhibitors?
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Good question… Of course, in the population the doctor is talking about in the above article the patients are diabetic, and on keto and taking SGLT2 inhibitors…
Not enough is known about these risks in healthy populations.
adssx
#4
It’s quite well-known that there’s a risk of DKA for people on keto + SGLT2i.
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PBJ
#5
From what I understand, the risk of diabetic ketoacidosis (DKA) with SGLT2 inhibitors is low in individuals who do not have type 2 diabetes. That said, if you’re concerned, it’s wise to start with a low dose and monitor your ketone levels. I recommend using something like the Keto Mojo for this.
I’m on a calorie-restricted diet (not ketogenic), and when I started dapagliflozin at 5 mg, my morning ketone levels measured around 3.0 mmol/L. Based on what I’ve read, ketone levels around 7.0 mmol/L can be a red flag for potential ketoacidosis, especially in people with diabetes.
Always good to be cautious and keep an eye on biomarkers when starting something new.
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Same risk for non diabetic on tirzepatide
The risk seem to be at least as high with retatrutide since pass a certain dosage on it you are naturally in ketosis, regardless of your diet.
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I will add to it that one of my best friends here in Hong Kong, a guy from the UK with CVD, experienced Ketoacidosis from his SGLT2I. So, it definitely occurs and is not as rare as you may think.
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adssx
#8
Do you know which SGLT2i he was using? Is he on a low carb diet? Or doing intermittent fasting?
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He’s using dapagliflozin. I haven’t talked to him in detail about his diet though. I think he mentioned he may be doing OMAD. I’ll have to double check as I wasn’t paying too much attention to that at the time.
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I take dapagliflozen. I haven’t had any issues when doing my FMD (3 times now) during which I do cardio and resistance training. I can feel the low glycogen in my legs but I’m not experiencing low blood sugar or very high ketones in any way I can feel. I mention it to say that keto acidosis not guaranteed to happen (sglt2 + keto) even though it’s a risk.
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