When a GLP-1-based drug is added to insulin, doses often come down, and the drug's commonest effects are nausea, vomiting and reduced intake. In type 1 diabetes, and in insulin-deficient type 2 diabetes, that combination is the setting for ketoacidosis, sometimes with near-normal glucose if an SGLT2 inhibitor is also used.
The fix is a conversation and a plan at the time of starting, not a new test.
- Never stop basal insulin entirely in type 1 diabetes, even when eating little.
- Teach blood or urine ketone checks when vomiting, and give a threshold for seeking care.
- Advise pausing an SGLT2 inhibitor during acute illness or reduced intake.
- Write the sick-day plan down; verbal advice given at a busy start is often forgotten.
Why it matters
The gastrointestinal effects that make these drugs work are the same ones that tip insulin-deficient patients into ketosis.
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