---
title: Caution Combining SGLT-2 Meds & Low Carb Diets
description: A recent case report of ketoacidosis in an individual taking a sodium-glucose cotransporter-2 inhibitor (SGLT2i) medication while following a ketogenic diet highlights the possibility for developing ketoacidosis when these two therapies are combined. As explained in a previous article, nutritional ketosis induced via a very low carbohydrate intake is different from diabetic ketoacidosis. However, practitioners should be aware of the dangers of introducing an SGLT2i in someone following a ketogenic diet, or of encouraging adoption of a keto diet in someone taking an SGLT2i if the medication is not deprescribed.
---

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# [Caution Combining SGLT-2 Meds & Low Carb Diets](https://info.bioticsresearch.com/researchforum/caution-combining-slg-2-meds-low-carb-diets)

 Written by [The Biotics Research Team](https://info.bioticsresearch.com/researchforum/author/the-biotics-research-team) | Apr 18, 2022 2:25:53 PM

A recent [case report of ketoacidosis](https://journals.sagepub.com/doi/full/10.1177/11795476221090045) in an individual taking a sodium-glucose cotransporter-2 inhibitor (SGLT2i) medication while following a ketogenic diet highlights the possibility for developing ketoacidosis when these two therapies are combined. As explained [in a previous article](https://blog.bioticsresearch.com/keto-diet-myths-part-2), nutritional ketosis induced via a very low carbohydrate intake is different from diabetic ketoacidosis. However, practitioners should be aware of the dangers of introducing an SGLT2i in someone following a ketogenic diet, or of encouraging adoption of a keto diet in someone taking an SGLT2i if the medication is not deprescribed.

The situation detailed in [*Clinical Medicine Insights: Case Reports*](https://journals.sagepub.com/doi/full/10.1177/11795476221090045) involved a 58-year-old male with hypertension and non-insulin dependent type 2 diabetes. He presented to the hospital after two days of generalized weakness, fatigue, confusion and slurred speech. His blood glucose was 373 mg/dL and blood beta-hydroxybutyrate (BOHB) level concentration was 9.8 mmol/L. (The normal range for the latter in an individual not following a ketogenic diet is approximately 0.0-0.3 mmol/L. A ketogenic diet typically results in BOHB levels < 5.0 mmol/L and even an extended fast would typically [not result in BOHB > 7.0 mmol/L](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617348/).) Various other measurements confirmed acidemia and diabetic ketoacidosis (DKA).

It's important to emphasize that ketogenic diets, by themselves, do not induce ketoacidosis, and there have been numerous reports of [ketoacidosis in patients using SGLT2i medications](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012260/) *not* in conjunction with low-carb or keto diets, so this risk is not limited solely to those following such diets. Something else to be aware of is that it may present as [*euglycemic *ketoacidosis](https://pubmed.ncbi.nlm.nih.gov/33563658/), so the signs and symptoms of DKA may be present even glucose is normal or only slightly elevated, which could delay diagnosis.

It is not a ketogenic diet, by itself, that induces acidosis, but rather, use of SGLT2i medication in conjunction with carbohydrate restriction. (See examples [here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578500/) and [here](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971428/).) It’s not known [for certain what the mechanism is](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012260/) by which these drugs induce ketoacidosis, but it may be that they cause the kidneys to reabsorb ketone bodies, and they also [increase glucagon secretion](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727509/) while decreasing insulin secretion, which would stimulate breaking down fat and raising ketones. (And again, there have been reports of DKA induced by SGLT2is in patients not following low-carb diets.)

The patient in this recent case report “was educated on the importance of avoiding a ketogenic diet and intermittent fasting while on an SGLT-2 inhibitor.” However, considering the [impressive efficacy of carbohydrate restriction](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537012/) on improving or even reversing type 2 diabetes, for some patients it may be prudent to take the opposite approach: “prescribe” a very low-carb diet and avoid the medication. Indeed, physicians who employ low-carb or ketogenic diets for patients with type 2 diabetes typically discontinue or [deprescribe SGLT2is “early on](https://www.mdpi.com/1660-4601/17/7/2557/htm)” or [“immediately”](https://pubmed.ncbi.nlm.nih.gov/32740047/) upon adoption of such dietary therapy in order to prevent ketoacidosis.

[View full post](https://info.bioticsresearch.com/researchforum/caution-combining-slg-2-meds-low-carb-diets)

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