Patients with type 1 diabetes are facing the sobering outlook that today despite improvements in insulin therapy they are prone to increased cardiovascular mortality. The onset of type 1 diabetes before age 10 has been associated with 17 years loss of life in girls and 14 years in boys. In addition, increasing incidence of overweight, hypertension and negative psychosocial consequences due to unpredictable glucose swings are other unmet needs that potentially can be addressed by adjunct therapy with SGLT inhibitors.
Dapagliflozin and sotagliflozin have been approved for adjunct therapy in certain patients with type 1 diabetes in Europe. In Germany, the Federal Joint Committee (G-BA), the highest decision-making body of the joint self-government of physicians, hospitals and health insurance funds, has recently issued a positive benefit assessment for dapagliflozin. Also, in the UK, the cost-effectiveness estimate for dapagliflozin plus insulin compared with insulin alone was judged to be within the range that NICE normally considers an acceptable use of NHS resources. Certainly this therapy is not suited for every patient with type 1 diabetes.
Current prerequisites for adjunct therapy with SLT inhibitors include a body mass index (BMI) of at least 27 kg/m2, when insulin alone does not provide adequate glycemic control despite optimal insulin therapy, and if patients have completed a structured education program about diabetic ketoacidosis. Treatment should be started and supervised by a consultant physician specializing in diabetes. Evidence from the clinical trials show small improvements in HbA1c levels and increases of up to 3 hours time in range by CGM as well as an average weight loss of 3kg in overweight individuals, and improvements in quality of life, when SGLT inhibitors plus insulin are compared with placebo plus insulin in adults with type 1 diabetes.
Thus, adjunct therapy should be initiated in adults with type 1 diabetes if an individual risk / benefit assessment as outlined above indicates the likelihood of positive outcomes.