A joint perspective from endocrinology, nephrology and cardiology sets out why people with type 1 diabetes have been left out of the cardiorenal gains their type 2 counterparts have had, and what it would take to fix that. The argument is mechanistic: the pathways through which SGLT inhibitors protect heart and kidney in type 2 diabetes and in non-diabetic kidney disease are not glucose-dependent, so there is no good reason to expect them to fail in type 1.
The practical proposal is about trial design. Powering a type 1 trial for hard cardiovascular or renal events would need a population and a follow-up nobody is going to fund. The authors argue that surrogate endpoints — the kind already accepted in nephrology — would make registrational trials feasible, provided ketoacidosis data are collected rigorously rather than as an afterthought.
Nothing here changes prescribing today. Ketoacidosis remains the reason these drugs are not licensed in type 1 diabetes in most jurisdictions, and mitigation protocols exist but have never been tested with the rigour the risk deserves. What this does change is what to say to the patient with type 1 diabetes and declining kidney function who has read about these drugs: the evidence gap is a trial-design problem being actively worked on, not a settled verdict against them.
- Do not start an SGLT inhibitor off-licence in type 1 diabetes on the strength of type 2 data
- Where one is already in use, confirm the patient has ketone strips and knows the sick-day rules
- Record the indication and the ketoacidosis counselling in the notes if you continue an existing off-licence prescription
- Check CDSCO labelling before assuming an agent licensed abroad for type 1 is licensed here — for SGLT inhibitors it generally is not
Why it matters
People with type 1 diabetes and kidney disease have no cardiorenal agent of their own, and this names the trial-design reason rather than a biological one.
Don't overread it
This is an expert perspective proposing a research pathway, not new trial data and not a change in licensing.
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