Continuous Ketone Monitoring May Guide SGLT2i Use in T1D

Continuous ketone monitoring (CKM) is emerging as a companion to continuous glucose monitoring (CGM), offering clinicians real-time insight into a complication long feared with sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy: euglycemic diabetic ketoacidosis (DKA). The technology could reshape how the drug class is used in type 1 diabetes (T1D), where kidney-protective benefits have been weighed against ketoacidosis risk.

On a recent episode of Diabetes Dialogue, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, discussed early clinical experience with CKM technology, drawing on patient cases presented at an interactive Medscape education program the month prior.

Watch the full episode, featuring tech, screening, and care updates from ADCES 2026, here.

One case involved a patient with new-onset T1D, believed to be latent autoimmune diabetes in adults, who was managed on an SGLT2 inhibitor without insulin. Ketone testing showed moderate elevation, prompting discussion of when to initiate insulin or discontinue the SGLT2 inhibitor rather than waiting for symptoms to emerge. The case illustrated the diagnostic gap CKM is designed to close, since intermittent point-of-care ketone checks can miss the gradual rise associated with euglycemic DKA.

Clinicians are increasingly interested in extending SGLT2 inhibitor therapy, even at reduced doses, to patients with T1D for its cardiorenal protective effects, particularly in those who cannot tolerate metformin or a GLP-1 receptor agonist. The barrier remains the elevated euglycemic DKA risk unique to T1D. Continuous ketone data could allow clinicians to identify early metabolic drift and intervene before ketoacidosis develops, potentially expanding safe access to the drug class.

A second case centered on a pregnant patient carrying twins and using a connected insulin pen, where ketone monitoring supported decisions around nutritional adequacy and DKA prevention during a period of heightened metabolic risk. The discussion underscored how CKM may extend beyond T1D management to support other high-risk populations.

Both speakers acknowledged clinicians have limited experience interpreting continuous, rather than intermittent, ketone data, and said real-world device use will help define appropriate thresholds and interventions. As CKM systems reach wider clinical availability, the technology is positioned to refine risk stratification for SGLT2 inhibitor therapy in T1D and other high-risk metabolic states.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others.

References

1. Fernando K, Akturk H. Present and Future of Continuous Ketone Monitoring: Risky or Rewarding? Medscape. July 10, 2026. Accessed August 12, 2026. https://www.medscape.com/viewarticle/present-and-future-continuous-ketone-monitoring-risky-or-2026a1000mym