Non-insulin therapies in addition to insulin in Type 1 DM treatment

Introduction: Complications of Type 1 diabetes (T1DM) remain prevalent due to suboptimal glycaemic control despite advances in analogue insulin, its delivery and technological advances in glucose monitoring. Intensive insulin therapy is associated with hypoglycaemia and weight gain. Non-insulin-dependent glucose lowering strategies may provide a strategy in improving glycaemic control without hypoglycaemia and weight gain.

Sources of data: Research papers and reviews about adjunctive treatment with insulin in T1DM in the published literature.

Areas of agreement: Non-insulin-dependent strategies may be beneficial inT1DM particularly when there is insulin resistance, but the evidence for benefit at the current time is limited. Although there have been trials with various drugs as adjunctive therapy to insulin in T1DM currently in the UK, there is only one sodium glucose transport protein 2 (SGLT2) inhibitor with a marketing authorization for use in this indication.

Areas of controversy: Potential for harm with SGLT2 inhibitors in T1DM is a potential issue, particularly euglycaemic diabetic ketoacidosis. Clinical trials confirm that there is a risk albeit small, but emerging safety data have led to questions as to whether the risk of euglycaemic diabetic ketoacidosis is higher with the use of SGLT2 inhibitors in clinical practice.

Growing points: Patient education is paramount-the work being done in T1DM to ensure safe use of SGLT2 inhibitors may help improve safety in the prescribing of SGLT2 inhibitors in Type 2 diabetes.

Areas timely for developing research: There is a need for larger clinical trials with SGLT2 inhibitors in T1DM and real world studies to clarify safety.