Nezam El-Tayebat Fact CheckA scientific assessment of the “نظام الطيبات” nutrition system
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True Scientifically well supported Certainty of evidence: high provisional C-ODD-02

SGLT2 inhibitors such as dapagliflozin (Forxiga) can cause ketoacidosis, sometimes with normal or low blood glucose.

Safety note: High blood glucose together with ketones (acetone) in urine or blood, especially with nausea, vomiting, abdominal pain, rapid breathing, thirst or drowsiness, can mean diabetic ketoacidosis, a medical emergency. In people taking SGLT2 inhibitors (e.g. dapagliflozin/Forxiga, empagliflozin) ketoacidosis can occur with normal, only mildly raised or even low glucose; prolonged fasting, very-low-carbohydrate eating, illness, dehydration or reducing insulin increase this risk. Seek emergency care; do not wait or fast it out. Do not stop or change diabetes medication without the treating physician.
In short: This claim is true. SGLT2 inhibitors such as dapagliflozin roughly double the rare risk of diabetic ketoacidosis (about 2 extra cases per 1,000 people over 5 years), and this ketoacidosis can occur with normal or, rarely, low blood glucose, especially during fasting; this is a reason for precautions, not proof that the drugs are net harmful.
Conclusion: True: SGLT2 inhibitors such as dapagliflozin roughly double a rare risk of ketoacidosis, which can occur with normal or even low blood sugar, especially during fasting; this calls for precautions, not for avoiding a drug with proven benefits.
  1. Original statement
  2. Scientific assessment
  3. Scientific evidence in detail
  4. In plain language
  5. Studies on this claim
  6. Regional context
  7. What applies in my country?
  8. References

Original statement

الفروسيجا عمل نفس تاثير المجاعه على جسم حضرتك سكر طبيعي او تحت الطبيعي ومعاه كيتو اسيدوزيس

verbatim according to source. Translation by the project; the Arabic wording is authoritative.

Translation

SGLT2 inhibitors such as dapagliflozin (Forxiga) can cause ketoacidosis, sometimes with normal or low blood glucose.

Origin

Source status
Video transcript (own words)
Attribution
Elawady (machine transcript)
Video
الغيبوبات السكرية ؟! (Open source)
Published
30 April 2025
Timestamp
0:10:54 (location in the original video’s automatic YouTube caption track; confirms where the words occur, not who speaks)
Attribution uncertainty
Archive transcript (YouTube CC or AI-generated); no timestamps; 'published' is the date listed by the archive and may be the upload date. Live-stream transcripts can contain viewer comments read aloud; the quoted passage was checked in context to be spoken by Elawady.
Claimed mechanism

Glucose loss in urine mimics starvation; ketogenesis continues.

Claimed health effect

Ketoacidosis (euglycaemic DKA)

Population concerned

SGLT2 inhibitor users

Geographic restriction by Elawady

none found

Diverging source versions

Source status
Archive quote (no location given)
Attribution
Elawady (archive paraphrase; source video not given)
Origin
https://eltayebat.com/rule/oral-diabetes-drugs/
Attribution uncertainty
The archive's 'د. ضياء يقول' box gives no video reference; wording is the archive's paraphrase.

ايه بتحصل فيها المجعات ومع المجهود البدني العنيف زي ده واحد دخل في مقاتله عنيفه حتى الموت او مجاعه استمدت لشهور او دواء مشهور قوي اسمه الفورسيجا الفورسيجا ده من اقذر من اقذر ما يمكن يعني انا ما شفتش ادويه اقذر منه غير

Forxiga (dapagliflozin) is among the 'dirtiest' drugs he has seen; like starvation lasting months or extreme physical exertion, it can lead to ketoacidosis.

Source status
Video transcript (own words)
Attribution
Elawady (machine transcript)
Video
Dr.D Clinics - Diaa Al Awady is live! الغيبوبة الكيتونية (Open source)
Published
23 April 2025
Timestamp
0:47:36 (location in the original video’s automatic YouTube caption track; confirms where the words occur, not who speaks)
Attribution uncertainty
Archive transcript (YouTube CC or AI-generated); no timestamps; 'published' is the date listed by the archive and may be the upload date. Live-stream transcripts can contain viewer comments read aloud; the quoted passage was checked in context to be spoken by Elawady.

Scientific assessment

True – The statement is supported by robust evidence.

Certainty of evidence: high – Further research is very unlikely to change the assessment.

1. What was claimed?

Forxiga causes ketoacidosis even with normal glucose.

2. What is demonstrably correct?

The claim is correct. SGLT2 inhibitors about double the risk of DKA: OR 2.07 (1.44-2.98), high certainty, about 2 extra cases per 1,000 people over 5 years (I-ODD-107); RR 2.12 (1.49-3.04) in 13 large blinded trials, from a placebo rate of about 0.2 per 1,000 patient-years (I-ODD-106); with dapagliflozin specifically 0.3% vs 0.1% in DECLARE-TIMI 58 (I-ODD-105); cohort HR 2.85 vs DPP-4 inhibitors (I-ODD-09); adjudicated CREDENCE data 11 vs 1 cases (I-ODD-05). Ketoacidosis often presents with normal or only mildly raised glucose (median 10.6 mmol/L in 1,024 published cases, I-ODD-104; I-ODD-10), and 15 published cases occurred with glucose below 100 mg/dL, 11 of them after fasting or poor intake (I-ODD-128). ADA 2026 lists very-low-carbohydrate diets and prolonged fasting as risk factors and reports a 5-17-fold risk in type 1 diabetes (I-INS-10). The mechanism described (urinary glucose loss producing a starvation-like ketotic state) is the accepted explanation.

3. What is wrong or exaggerated?

Nothing in this statement itself. The risk is rare in type 2 diabetes (about 0.2-2 per 1,000 patient-years) and does not make the drug net harmful: in the same trials dapagliflozin reduced heart-failure hospitalisation and kidney events (I-ODD-105) and death in heart failure and CKD (I-ODD-04, I-ODD-03); across 13 trials about 26 serious events were avoided for every 2 caused per 1,000 patient-years in CKD with diabetes (I-ODD-106). Elawady's conclusion that Forxiga is one of the 'dirtiest' drugs is assessed separately (C-ODD-06, “False”).

4. What remains unclear?

The ketoacidosis risk of SGLT2 inhibitors during prolonged fasting or very low-carbohydrate eating, as promoted in the system, has not been measured in trials; the data come from cohorts, case series and trial programmes. No risk estimates for Egyptian patients were found.

5. Which studies support it?

I-ODD-107 (NMA, high certainty), I-ODD-106 (13 blinded RCTs), I-ODD-105 (DECLARE, dapagliflozin), I-ODD-103 (meta-analysis RR 2.46), I-ODD-05 (CREDENCE), I-ODD-09 (cohort), I-ODD-104 and I-ODD-10 (euglycaemic presentation), I-ODD-128 (low-glucose cases), I-INS-10 and I-ODD-16 (ADA 2026), A-ODD-10 and A-ODD-11.

6. Which studies contradict it?

No high-quality evidence contradicts the DKA risk. A small Egyptian cohort found no DKA among 61 patients starting SGLT2 inhibitors during supervised Ramadan fasting (I-ODD-129), which is too small to exclude a rare event. Net-benefit evidence (I-ODD-02, I-ODD-03, I-ODD-04, I-ODD-106) concerns a different question (C-ODD-06).

7. What applies to Germany and Europe?

EMA/BfArM product information for SGLT2 inhibitors carries the same DKA warning (not separately fetched).

8. What is known about Egypt?

Egypt has one of the highest diabetes prevalences in the region; the same drug classes and insulins are used. Access barriers and cost may make advice to stop medication attractive, which increases the practical risk of this claim. No Egypt-specific evidence changes the assessment.

9. What practical conclusion is appropriate?

The DKA risk is real and makes it especially dangerous to combine SGLT2 inhibitors with prolonged fasting, very-low-carbohydrate eating or insulin reduction, as the Tayebat system suggests. ADA 2026 recommends education, ketone testing and avoiding ketogenic eating patterns on these drugs. The answer is informed use with sick-day rules, not rejection of a drug with proven heart and kidney benefit.

Assessment details

Rationale for certainty of evidence

High-certainty randomised evidence: a network meta-analysis of 816 RCTs rated the DKA increase with SGLT2 inhibitors as high certainty (OR 2.07, 1.44-2.98; about 2 more per 1,000 over 5 years) (I-ODD-107); a meta-analysis of 13 large blinded trials found RR 2.12 (1.49-3.04) in people with diabetes (I-ODD-106); in the dapagliflozin trial DECLARE-TIMI 58, DKA occurred in 0.3% vs 0.1% (I-ODD-105). Normal-glucose presentation is typical (median 10.6 mmol/L in 1,024 published cases, I-ODD-104), and rare cases occur with glucose below 100 mg/dL, mostly after fasting (I-ODD-128). Absolute risk in type 2 diabetes is low (about 0.2-2 per 1,000 patient-years) and higher in type 1 diabetes (ADA 2026: 5-17 times).

Source quality

Own words plus archive paraphrase; Elawady's description of euglycaemic ketoacidosis is essentially correct.

Regional transferability

Universal.

Individual exceptions

Risk higher in type 1 diabetes/insulin deficiency, low-carbohydrate diets, fasting, surgery, acute illness, alcohol.

Regional scope of the claim
general (biological/medical)
Last reviewed
26 October 2026 provisional

Scientific evidence in detail

Scientifically well supported – The claim agrees with consistent, high-quality evidence.

Research question: In people taking SGLT2 inhibitors such as dapagliflozin, does the risk of diabetic ketoacidosis increase, and does ketoacidosis occur with normal or low blood glucose?

Research question in detail (PICO)
Population
People with type 2 (and type 1) diabetes, and non-diabetic users for heart failure/CKD
Intervention or exposure
SGLT2 inhibitors (dapagliflozin, empagliflozin, canagliflozin)
Comparison
Placebo or other glucose-lowering drugs
Geographic scope
universal biology; fasting practices relevant to Egypt
Outcomes
  • Diabetic ketoacidosis
  • Glucose level at DKA presentation
  • Precipitating factors (fasting, low-carbohydrate intake)

Study results as reported by the authors. Our assessment follows below.

What speaks for the claim?

What speaks against the claim?

What does the overall evidence say?

Editorial assessment based on the studies above – not itself a study result.

Which position is better supported?

The claim is correct. SGLT2 inhibitors about double the risk of diabetic ketoacidosis (absolute risk about 0.2-2 per 1,000 patient-years in type 2 diabetes, higher in type 1 diabetes), and this ketoacidosis often presents with normal or only mildly raised glucose; rare cases occur with low glucose, mostly after fasting or poor food intake.

Why some studies weigh more

Randomised evidence (Shi 2023 NMA, SMART-C, DECLARE for dapagliflozin specifically) establishes the risk; case series establish the euglycaemic and hypoglycaemic presentations. The small Egyptian cohort is too small to weigh against this.

Is a causal relationship established? Yes, established Randomised placebo-controlled trials show a consistent increase; the mechanism (glucosuria lowers insulin needs and raises glucagon, mimicking starvation ketosis) is accepted.

Remaining uncertainty

Absolute risk during prolonged fasting or very-low-carbohydrate eating has not been measured in trials.

Justified conclusion

The statement about ketoacidosis is true. It is a reason for precautions (sick-day rules, ketone testing, avoiding ketogenic diets and prolonged fasting without medical advice), not evidence that the drugs are net harmful (see C-ODD-06).

Why do studies seem to disagree?

Palmer 2021 (BMJ NMA; not added) judged no DKA increase with moderate certainty, whereas the larger 2023 update by the same evidence programme (I-ODD-107) and SMART-C (I-ODD-106) found about a doubling with high certainty. The difference reflects more trials and events, not a true disagreement. The Egyptian Ramadan cohort (I-ODD-129) studied supervised short daytime fasting with education and dose adjustment, a different exposure from unsupervised prolonged fasting.

Does this depend on the country?
General biological effects
Drug pharmacology and physiology are universal.
Eating habits
Prolonged fasting, Ramadan fasting and very-low-carbohydrate eating change the risk of hypoglycaemia and ketoacidosis with some drugs; relevant in Egypt and among Muslims in Europe.
Origin of the food
Not applicable.
Contaminants
Not applicable.
National production conditions
Not applicable (same active substances; generics widely used in Egypt).
Legal rules
Drug labels and warnings are set by FDA/EMA and national regulators; Egyptian labelling not reviewed.
Actual monitoring data
No Egypt-specific pharmacovigilance data were found for this outcome.

A regional difference that changes the conclusion is not supported by robust data.

Statistical re-check
  • CI symmetry and absolute excess from placebo rate – RR 2.12 (1.49-3.04) symmetric; excess about 0.22 per 1,000 PY (0.10-0.41). recalculated
  • Absolute risk from OR and baseline 0.2% – 0.2% -> 0.41% over 5 years; 2.1 per 1,000 extra (paper: 2). recalculated
  • NNH from rounded DKA percentages – 0.3% vs 0.1% -> NNH about 500 over 4.2 years (rounding uncertainty). recalculated
  • CI symmetry – RR 2.46 (1.16-5.21) and 1.74 (1.07-2.83) symmetric. recalculated
Certainty of the overall evidence (GRADE, simplified)
Main outcome
Diabetic ketoacidosis with SGLT2 inhibitors vs placebo/comparators in type 2 diabetes
Starting level
high (randomised trials)
Result
high

Simplified assessment by a single reviewer, following the GRADE approach; not a formal GRADE panel. GRADE rates the body of evidence for one outcome, not individual studies.

Clinical guidelines and official statements checked
  • ADA: 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026 (2026) · Original publication
    DKA uncommon in type 2 diabetes on SGLT2i (0.6-4.9 per 1,000 patient-years); RCT meta-analysis RR 2.46; risk factors include very-low-carbohydrate diets and prolonged fasting; type 1 diabetes risk 5-17 times higher; people on intensive insulin should not stop basal insulin even if not eating.
  • ADA: 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2026 (Diabetes Care 2026;49 Suppl 1) (2026) · Original publication
    Educate people at risk of DKA on SGLT inhibition about signs and risk mitigation, provide ketone testing tools and discourage a ketogenic eating pattern (rec. 9.39).
  • NICE: Type 2 diabetes in adults: management (NG28), last updated 18 February 2026 (2026) · Original publication
    1 in 1,000 or fewer people would experience rarer events like DKA or Fournier gangrene; for most people benefits outweigh risks.
Search strategy

Documented literature searches for this review (search strings in the original database syntax).

DatabaseDateSearchLooking forHitsIncluded
Europe PMC26 October 2026("SGLT2" OR "sodium-glucose cotransporter-2" OR "SGLT-2") AND ("diabetic ketoacidosis") AND ("meta-analysis") AND ("randomized" OR "randomised")supporting evidence1724
PubMed26 October 2026(euglycemic[tiab] OR euglycaemic[tiab]) AND ketoacidosis[tiab] AND (SGLT2[tiab] OR gliflozin*[tiab] OR dapagliflozin[tiab]) AND (systematic review[pt] OR meta-analysis[pt] OR systematic[ti])supporting evidence9
PubMed26 October 2026Colacci M[au] AND ketoacidosis[ti]supporting evidence4
Europe PMC26 October 2026(SGLT2 OR "SGLT-2" OR dapagliflozin OR empagliflozin) AND Ramadan AND (ketoacidosis OR ketone OR safety) AND (Egypt OR Arab OR Saudi OR Emirates OR "Middle East")both directions174
PubMed26 October 2026(dapagliflozin[ti] OR empagliflozin[ti] OR "SGLT2 inhibitors"[ti]) AND (ketoacidosis[tiab]) AND (placebo[tiab]) AND (randomized controlled trial[pt]) AND 2019:2026[dp]contradicting evidence21
Europe PMC26 October 2026(TITLE:"SGLT2" OR TITLE:"SGLT-2" OR TITLE:"sodium-glucose") AND (mortality OR "kidney outcomes") AND ("meta-analysis") AND ("randomised" OR "randomized") AND PUB_YEAR:[2021 TO 2026]contradicting evidence1300
PubMed26 October 2026(Egypt*[tiab]) AND (SGLT2[tiab] OR "SGLT-2"[tiab] OR dapagliflozin[tiab] OR empagliflozin[tiab]) AND (ketoacidosis[tiab] OR safety[tiab] OR adverse[tiab] OR Ramadan[tiab])both directions4
ADA Standards of Care 2026, Section 6 (PubMed Central)26 October 2026Fetched https://pmc.ncbi.nlm.nih.gov/articles/PMC12690178/; keyword review: SGLT, euglycemic, ketoacidosis. The diabetesjournals.org DOI landing pages returned HTTP 403; the identical article was read in PubMed Central.guidelines1
NICE NG28 (2026)26 October 2026Fetched https://www.nice.org.uk/guidance/ng28/chapter/Initial-medicines; chapter Initial medicinesguidelines1

Open questions

DKA incidence in people who combine SGLT2 inhibitors with prolonged fasting or the Tayebat diet has not been studied.

How deeply was this checked?

17 linked studies: 8 checked in full text (4 of them with a structured risk-of-bias assessment), 9 on the basis of the abstract, 0 bibliographically only. No formal assessment with two independent reviewers and no independent human expert review has taken place yet.

Last scientific review: 26 October 2026

History of the verdict
  1. 25 October 2026 · Phase 1 · Initial assessment: Mostly true (moderate)
  2. 26 October 2026 · Phase 4 (systematic evidence review) · Verdict changed: Mostly true (moderate) → True (high)
    The previous downgrade from “True” was justified by the use of this fact to argue net harm; that argument belongs to C-ODD-06 (rated “False”). Judged on its own wording, the claim is correct, and the evidence base now includes a high-certainty RCT network meta-analysis (I-ODD-107), a meta-analysis of 13 large blinded trials (I-ODD-106), dapagliflozin-specific RCT data (I-ODD-105) and documentation of normal- and low-glucose presentations (I-ODD-104, I-ODD-128).
    New sources: I-ODD-103 I-ODD-104 I-ODD-105 I-ODD-106 I-ODD-107 I-ODD-128 I-ODD-129 I-ODD-126

In plain language

Drugs like Forxiga make the body lose sugar in the urine. This can, rarely, lead to a dangerous acid build-up (ketoacidosis), and the blood sugar may look normal or even low when it happens, especially during fasting, illness or very low-carbohydrate eating. Large trials show the risk is about doubled but still small, about 2 extra cases per 1,000 people over 5 years. At the same time, these drugs reduce heart failure, kidney failure and deaths in people at risk. Anyone on these drugs who feels sick, vomits or breathes fast should seek care and have ketones checked, even if the sugar looks normal.

Studies on this claim

Studies supporting the claim (12)

  • Ketoacidosis with canagliflozin

    Erondu N et al.. Diabetes Care 2015 · PMID 26203064 · DOI 10.2337/dc15-1251
    Othercited by the Tayebat archivefull text, structured risk-of-bias assessment

    Ketoacidosis was rare (7 per 10,000 patients), often with insulin deficiency or triggers.

    Does the study support the specific claim? Partly · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Incidence of DKA with canagliflozin

    How was the study done?

    Pooled safety analysis of randomised trials

    How many people, animals or samples were studied?

    17,596; Type 2 diabetes in canagliflozin program

    What was actually found?

    DKA 0.07%.

    How large was the observed effect?

    0.52-0.76 vs 0.24 per 1,000 PY

    What do the results mean in everyday life?

    Rare but real risk.

    What are the study's limitations?

    Analysed and written by manufacturer employees; only 12 cases; based on investigator reports (may miss cases).

    What does it say about Elawady's specific claim?

    Supports C-ODD-02; mixed for C-INS-08.

    Do the results apply to Germany and Europe?

    Multinational/US/UK data; transferable to EU practice.

    What can explicitly not be concluded from this study?

    Precise relative risk; that euglycaemic DKA is common (cases here had high glucose).

    Scientific details →

  • Ketoacidosis after starting SGLT2 drugs (letter)

    Fralick M et al.. N Engl J Med 2017 · PMID 28591538 · DOI 10.1056/NEJMc1701990
    Cohort studycited by the Tayebat archiveabstract checked

    Content not verified (no abstract).

    Does the study support the specific claim? Unclear · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Risk of DKA after initiating an SGLT2 inhibitor (per title)

    How was the study done?

    Research letter (no abstract in PubMed; full text not accessed)

    How many people, animals or samples were studied?

    not verifiable; not verifiable

    What was actually found?

    Not verified.

    How large was the observed effect?

    not verified

    What do the results mean in everyday life?

    See I-ODD-09.

    What are the study's limitations?

    Not read; letter format

    What does it say about Elawady's specific claim?

    Supports C-ODD-02 (direction).

    Do the results apply to Germany and Europe?

    US data.

    What can explicitly not be concluded from this study?

    Anything quantitative.

    Scientific details →

  • SGLT2 drugs and ketoacidosis

    Douros A et al.. Ann Intern Med 2020 · PMID 32716707 · DOI 10.7326/M20-0289
    Cohort studyindependent cross-checkabstract checked★ key study

    About 2 per 1,000 users per year developed ketoacidosis, nearly 3 times more than with DPP-4 drugs.

    Does the study support the specific claim? Yes · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    SGLT2 vs DPP-4 inhibitors and DKA risk

    How was the study done?

    Multicentre population-based cohort (prevalent new-user design, propensity-matched)

    How many people, animals or samples were studied?

    208,757 matched pairs; Type 2 diabetes new users

    What was actually found?

    HR 2.85.

    How large was the observed effect?

    HR 2.85 (1.99-4.08)

    What do the results mean in everyday life?

    Rare but real; caution with fasting/illness.

    What are the study's limitations?

    No lab data; Unmeasured confounding

    What does it say about Elawady's specific claim?

    Supports C-ODD-02; relevant to C-FAST-03.

    Do the results apply to Germany and Europe?

    UK data included.

    What can explicitly not be concluded from this study?

    That the drugs are net harmful.

    Scientific details →

  • Ketoacidosis with normal blood sugar on SGLT2 drugs

    Peters AL et al.. Diabetes Care 2015 · PMID 26078479 · DOI 10.2337/dc15-0843
    Case series / case reportindependent cross-checkfull text, structured risk-of-bias assessment

    Several patients developed ketoacidosis with near-normal sugar, so it was recognised late.

    Does the study support the specific claim? Yes · Methodological quality: very low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Describe euglycaemic DKA with SGLT2 inhibitors

    How was the study done?

    Case series

    How many people, animals or samples were studied?

    9 individuals, 13 episodes; Patients with T1D or T2D on SGLT2 inhibitors

    What was actually found?

    13 episodes in 9 patients on canagliflozin (7 with off-label type 1 diabetes); glucose often near normal, delaying diagnosis; all recovered with IV fluids and insulin.

    How large was the observed effect?

    not applicable

    What do the results mean in everyday life?

    Check ketones when unwell on SGLT2 drugs.

    What are the study's limitations?

    Incidental case collection, no denominator, mostly off-label type 1 use, all on canagliflozin.

    What does it say about Elawady's specific claim?

    Supports C-ODD-02; key for C-FAST-03 safety.

    Do the results apply to Germany and Europe?

    US.

    What can explicitly not be concluded from this study?

    How often this happens; that every SGLT2 inhibitor (e.g. dapagliflozin) carries the same risk (inferred, not shown here).

    Scientific details →

  • ADA guideline 2026: blood sugar goals and emergencies

    American Diabetes Association Professional Practice Committee for Diabetes* . Diabetes Care 2026 · PMID 41358894 · DOI 10.2337/dc26-S006
    Guideline / position statementindependent cross-checkfull text checked★ key study

    Most adults should aim for HbA1c below 7%, avoid low sugar, and measure ketones when at risk.

    Does the study support the specific claim? Partly · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Glycaemic goals, hypoglycaemia and hyperglycaemic crises

    How was the study done?

    Clinical practice guideline (ADA Standards of Care 2026, Section 6)

    How many people, animals or samples were studied?

    not applicable; People with diabetes

    What was actually found?

    Individual targets; do not stop basal insulin when not eating.

    How large was the observed effect?

    not applicable

    What do the results mean in everyday life?

    Moderate targets and safety rules.

    What are the study's limitations?

    US-centred; Partially read

    What does it say about Elawady's specific claim?

    Supports C-INS-04, C-INS-11; contradicts C-FAST-01, C-FAST-03, C-DIAB-02.

    Do the results apply to Germany and Europe?

    Consistent with EASD guidance.

    What can explicitly not be concluded from this study?

    Not applicable.

    Scientific details →

  • Canagliflozin in diabetic kidney disease

    Perkovic V et al.. N Engl J Med 2019 · PMID 30990260 · DOI 10.1056/NEJMoa1811744
    Randomised controlled trialindependent cross-checkfull text, structured risk-of-bias assessment★ key study

    Kidney failure and heart problems fell by about a third; amputations and fractures were not increased, but rare ketoacidosis was more common (11 vs 1 cases).

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Canagliflozin and renal outcomes in type 2 diabetes with nephropathy

    How was the study done?

    Double-blind placebo-controlled RCT (CREDENCE)

    How many people, animals or samples were studied?

    4,401; Type 2 diabetes with albuminuric CKD

    What was actually found?

    Primary kidney/heart outcome 43.2 vs 61.2 per 1000 patient-years (30% lower); amputation 12.3 vs 11.2 per 1000 patient-years (not significant); diabetic ketoacidosis 2.2 vs 0.2 per 1000 patient-years.

    How large was the observed effect?

    HR 0.70

    What do the results mean in everyday life?

    This drug class protects heart and/or kidneys in the studied patients.

    What are the study's limitations?

    Industry funded; stopped early for benefit; selected high-risk population; foot checks added during the trial may have lowered amputation risk; rare harms imprecise.

    What does it say about Elawady's specific claim?

    Contradicts C-ODD-06; limits amputation/fracture signals in C-ODD-05.

    Do the results apply to Germany and Europe?

    Multinational trial including European sites or directly applicable to EU practice.

    What can explicitly not be concluded from this study?

    Benefit in low-risk people; absence of side effects (ketoacidosis was increased); amputation safety in routine care without foot surveillance.

    Scientific details →

  • SGLT2 drugs roughly double the rare risk of ketoacidosis

    Colacci M et al.. Can J Diabetes 2022 · PMID 34116926 · DOI 10.1016/j.jcjd.2021.04.006
    Meta-analysisindependent cross-checkabstract checked★ key study

    RCTs: RR 2.46; absolute risk about 0.6-2.2 cases per 1,000 patient-years.

    RR 2.46 in RCTs, 1.74 in cohorts.

    Does the study support the specific claim? Yes · Methodological quality: moderate · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Quantify DKA risk with SGLT2 inhibitors.

    How was the study done?

    Meta-analysis of trials and cohorts.

    How many people, animals or samples were studied?

    About 360,000 participants.

    What was actually found?

    Higher DKA risk in trials and cohorts.

    How large was the observed effect?

    RR 2.46 (1.16-5.21) RCTs; RR 1.74 (1.07-2.83) cohorts.

    What do the results mean in everyday life?

    Rare but real; patients need sick-day rules and ketone checks.

    What are the study's limitations?

    Few trials, few events.

    What does it say about Elawady's specific claim?

    Supports the ketoacidosis part of the claim.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    It does not show the drugs are net harmful.

    Scientific details →

  • Ketoacidosis on SGLT2 drugs often comes with only mildly raised sugar

    Sharma A et al.. Diabetes Obes Metab 2025 · PMID 40919651 · DOI 10.1111/dom.70098
    Cohort studyindependent cross-checkabstract checked

    Published cases had median glucose 10.6 mmol/L despite severe acidosis (pH 7.1).

    Median admission glucose 10.6 mmol/L in 1,024 published cases; lower glucose than in non-users.

    Does the study support the specific claim? Yes · Methodological quality: moderate · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Describe DKA in SGLT2 inhibitor users.

    How was the study done?

    UK hospital cohort and review of published cases.

    How many people, animals or samples were studied?

    1,060 admissions; 1,024 published cases.

    What was actually found?

    Lower glucose and more acidosis in SGLT2i users; similar outcomes.

    How large was the observed effect?

    Median glucose 10.6 mmol/L; 21% ICU.

    What do the results mean in everyday life?

    Normal-looking sugar does not exclude ketoacidosis in people on these drugs.

    What are the study's limitations?

    No incidence data.

    What does it say about Elawady's specific claim?

    Supports the 'normal glucose' part.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    How often DKA occurs.

    Scientific details →

  • Forxiga in 17,160 people: fewer heart-failure admissions, rare ketoacidosis

    Wiviott SD et al.. N Engl J Med 2019 · PMID 30415602 · DOI 10.1056/NEJMoa1812389
    Randomised controlled trialindependent cross-checkabstract checked★ key study

    HF hospitalisation HR 0.73; renal events HR 0.76; DKA 0.3% vs 0.1%.

    DKA 0.3% vs 0.1% with dapagliflozin in a blinded RCT.

    Does the study support the specific claim? Partly · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Test cardiovascular safety and benefit of dapagliflozin.

    How was the study done?

    Blinded RCT vs placebo.

    How many people, animals or samples were studied?

    17,160 adults with type 2 diabetes.

    What was actually found?

    No change in heart attacks/strokes; fewer heart-failure hospitalisations and kidney events; slightly more DKA and genital infections.

    How large was the observed effect?

    HHF HR 0.73 (0.61-0.88); DKA +0.2 percentage points.

    What do the results mean in everyday life?

    The drug helps the heart and kidneys; a rare ketoacidosis risk requires precautions.

    What are the study's limitations?

    Industry-funded; few DKA events.

    What does it say about Elawady's specific claim?

    Supports the DKA part (C-ODD-02); contradicts 'dirtiest drug' and net harm (C-ODD-06).

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    Risk during prolonged fasting.

    Scientific details →

  • 13 large trials: SGLT2 drugs protect kidneys and heart; ketoacidosis rare

    Nuffield Department of Population Health Renal Studies Group; SMART-C Consortium. Lancet 2022 · PMID 36351458 · DOI 10.1016/S0140-6736(22)02074-8
    Meta-analysisindependent cross-checkfull text checked★ key study

    Kidney progression -37%, CV death -14%; DKA risk doubled from about 0.2 per 1,000 patient-years.

    DKA RR 2.12 in people with diabetes.

    Does the study support the specific claim? Partly · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Pool all large placebo-controlled SGLT2 inhibitor trials.

    How was the study done?

    Collaborative meta-analysis of 13 blinded RCTs.

    How many people, animals or samples were studied?

    90,409 participants.

    What was actually found?

    Clear kidney and heart benefits; DKA doubled but rare; amputation signal mainly from one trial.

    How large was the observed effect?

    RR 0.63 kidney; RR 0.86 CV death; DKA RR 2.12.

    What do the results mean in everyday life?

    For 1,000 people with diabetes and kidney disease treated for a year, about 26 serious events are avoided and about 2 caused.

    What are the study's limitations?

    Summary data; industry trials.

    What does it say about Elawady's specific claim?

    Confirms DKA risk, refutes net harm.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    Effects in people following prolonged fasting regimens.

    Scientific details →

  • 816 trials: what each diabetes drug class does and does not do

    Shi Q et al.. BMJ 2023 · PMID 37024129 · DOI 10.1136/bmj-2022-074068
    Meta-analysisindependent cross-checkfull text checked★ key study

    SGLT2 inhibitors and GLP-1 agonists reduce death by about 12%; each class has specific side effects.

    DKA OR 2.07, high certainty.

    Does the study support the specific claim? Partly · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Compare benefits and harms of all diabetes drug classes.

    How was the study done?

    Network meta-analysis of 816 RCTs with GRADE.

    How many people, animals or samples were studied?

    471,038 patients.

    What was actually found?

    Mortality benefit for SGLT2i and GLP-1 RA; class-specific harms such as DKA and genital infections (SGLT2i), hypoglycaemia (sulfonylureas, insulin), heart failure (TZDs).

    How large was the observed effect?

    Death OR 0.88; DKA OR 2.07; amputation OR 1.27.

    What do the results mean in everyday life?

    No drug is free of side effects; for several classes the benefits clearly outweigh them in people at risk.

    What are the study's limitations?

    Low certainty for older drugs.

    What does it say about Elawady's specific claim?

    Supports 'every class has harms'; refutes 'net harmful'.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    Individual treatment choice.

    Scientific details →

  • Ketoacidosis with low blood sugar on SGLT2 drugs: rare published cases, often after fasting

    Itagaki H et al.. J Clin Med 2026 · PMID 42882058 · DOI 10.3390/jcm15197595
    Case series / case reportindependent cross-checkabstract checked

    15 cases, median glucose 68 mg/dL; fasting or poor intake in 11 of 15.

    15 published cases with glucose <100 mg/dL; fasting precipitant in 11/15.

    Does the study support the specific claim? Yes · Methodological quality: very low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Describe ketoacidosis at low glucose in SGLT2 inhibitor users.

    How was the study done?

    Systematic review of case reports.

    How many people, animals or samples were studied?

    15 cases.

    What was actually found?

    Severe acidosis despite low sugar; fasting the main trigger.

    How large was the observed effect?

    Not applicable.

    What do the results mean in everyday life?

    On these drugs, a normal or low sugar reading does not rule out a dangerous acid build-up, especially when fasting.

    What are the study's limitations?

    Very small, case-based.

    What does it say about Elawady's specific claim?

    Supports the 'low glucose' part.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    How often it happens.

    Scientific details →

Studies contradicting or limiting the claim (4)

  • Empagliflozin heart trial

    Zinman B et al.. N Engl J Med 2015 · PMID 26378978 · DOI 10.1056/NEJMoa1504720
    Randomised controlled trialindependent cross-checkabstract checked★ key study

    Deaths fell from 8.3% to 5.7% over about 3 years.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    CV outcomes of empagliflozin in type 2 diabetes at high CV risk

    How was the study done?

    Double-blind placebo-controlled RCT (EMPA-REG OUTCOME)

    How many people, animals or samples were studied?

    7,020; Type 2 diabetes with high CV risk

    What was actually found?

    Primary 10.

    How large was the observed effect?

    HR 0.86; death -32%

    What do the results mean in everyday life?

    This drug class protects heart and/or kidneys in the studied patients.

    What are the study's limitations?

    Industry funded; Selected high-risk population

    What does it say about Elawady's specific claim?

    Contradicts C-ODD-06; context for C-ODD-02, C-ODD-08.

    Do the results apply to Germany and Europe?

    Multinational trial including European sites or directly applicable to EU practice.

    What can explicitly not be concluded from this study?

    Benefit in low-risk people; absence of side effects.

    Scientific details →

  • Dapagliflozin (Forxiga) in kidney disease

    Heerspink HJL et al.. N Engl J Med 2020 · PMID 32970396 · DOI 10.1056/NEJMoa2024816
    Randomised controlled trialindependent cross-checkfull text, structured risk-of-bias assessment★ key study

    Forxiga reduced kidney failure and deaths; the trial was stopped early because the benefit was clear.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Dapagliflozin in CKD with/without diabetes

    How was the study done?

    Double-blind placebo-controlled RCT (DAPA-CKD)

    How many people, animals or samples were studied?

    4,304; CKD (eGFR 25-75, albuminuria)

    What was actually found?

    Kidney failure, kidney decline or kidney/heart death: 9.2% with dapagliflozin vs 14.5% with placebo; deaths 4.7% vs 6.8%. Amputations 1.6% vs 1.8%; no ketoacidosis cases with dapagliflozin (2 with placebo).

    How large was the observed effect?

    HR 0.61; death HR 0.69

    What do the results mean in everyday life?

    This drug class protects heart and/or kidneys in the studied patients.

    What are the study's limitations?

    Industry funded; stopped early for benefit (can overstate effect); selected high-risk CKD population; type 1 diabetes excluded; median 2.4 years follow-up.

    What does it say about Elawady's specific claim?

    Contradicts C-ODD-06 (Forxiga 'kills'); context for C-ODD-02.

    Do the results apply to Germany and Europe?

    Multinational trial including European sites or directly applicable to EU practice.

    What can explicitly not be concluded from this study?

    Benefit in low-risk people; absence of side effects.

    Scientific details →

  • Dapagliflozin in heart failure

    McMurray JJV et al.. N Engl J Med 2019 · PMID 31535829 · DOI 10.1056/NEJMoa1911303
    Randomised controlled trialindependent cross-checkabstract checked★ key study

    Fewer heart failure worsenings and deaths with Forxiga.

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Dapagliflozin in heart failure with reduced EF

    How was the study done?

    Double-blind placebo-controlled RCT (DAPA-HF)

    How many people, animals or samples were studied?

    4,744; HFrEF NYHA II-IV, EF <=40%, with/without diabetes

    What was actually found?

    Primary 16.

    How large was the observed effect?

    HR 0.74; death HR 0.83

    What do the results mean in everyday life?

    This drug class protects heart and/or kidneys in the studied patients.

    What are the study's limitations?

    Industry funded; Selected high-risk population

    What does it say about Elawady's specific claim?

    Contradicts C-ODD-06.

    Do the results apply to Germany and Europe?

    Multinational trial including European sites or directly applicable to EU practice.

    What can explicitly not be concluded from this study?

    Benefit in low-risk people; absence of side effects.

    Scientific details →

  • Egypt: no ketoacidosis in 61 patients starting SGLT2 drugs during Ramadan

    Khalil HAM et al.. J Diabetes Res 2025 · PMID 40322737 · DOI 10.1155/jdr/4321423
    Cohort studyindependent cross-checkfull text checked

    No DKA, hypoglycaemia or dehydration under supervision; study small and uncontrolled.

    No DKA among 61 Egyptian patients starting SGLT2i during supervised Ramadan fasting; too small to exclude a rare risk.

    Does the study support the specific claim? No · Methodological quality: low · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Test SGLT2 inhibitor safety during Ramadan in Egypt.

    How was the study done?

    Prospective before-after cohort.

    How many people, animals or samples were studied?

    61 patients.

    What was actually found?

    Better glucose control; no DKA.

    How large was the observed effect?

    0/61 DKA.

    What do the results mean in everyday life?

    With medical supervision and education, fasting on these drugs went without ketoacidosis in this small group.

    What are the study's limitations?

    Small, no control group.

    What does it say about Elawady's specific claim?

    Limits but does not refute the claim.

    Do the results apply to Germany and Europe?

    Moderate.

    What can explicitly not be concluded from this study?

    That the DKA risk is zero.

    Scientific details →

Studies with mixed or unclear results (1)

  • NICE 2026: offer metformin plus an SGLT-2 inhibitor to most adults with type 2 diabetes

    National Institute for Health and Care Excellence (NICE). NICE guideline 2026
    Guideline / position statementindependent cross-checkabstract checked★ key study

    Fewer heart events and heart-failure admissions; DKA and Fournier gangrene 1 per 1,000 or fewer.

    Acknowledges DKA as a rare risk (<=1 per 1,000).

    Does the study support the specific claim? No · Methodological quality: high · Certainty of evidence: see overall assessment of the claim

    Original publication · Scientific details

    Study explained simply
    What did the researchers want to find out?

    Recommend first-line diabetes medicines.

    How was the study done?

    Guideline based on meta-analyses.

    How many people, animals or samples were studied?

    Not applicable.

    What was actually found?

    Benefits outweigh risks for most people.

    How large was the observed effect?

    HF hospitalisation 54 vs 26-40 per 1,000 over 3 years.

    What do the results mean in everyday life?

    These medicines are recommended because they prevent heart problems.

    What are the study's limitations?

    UK context.

    What does it say about Elawady's specific claim?

    Contradicts net harm.

    Do the results apply to Germany and Europe?

    High.

    What can explicitly not be concluded from this study?

    Individual choices.

    Scientific details →

Regional context

Germany / EU

EMA/BfArM product information for SGLT2 inhibitors carries the same DKA warning (not separately fetched).

Egypt

Egypt has one of the highest diabetes prevalences in the region; the same drug classes and insulins are used. Access barriers and cost may make advice to stop medication attractive, which increases the practical risk of this claim. No Egypt-specific evidence changes the assessment.

What applies in my country?

General scientific assessment

True True: SGLT2 inhibitors such as dapagliflozin roughly double a rare risk of ketoacidosis, which can occur with normal or even low blood sugar, especially during fasting; this calls for precautions, not for avoiding a drug with proven benefits.

This statement concerns biological or medical relationships. The scientific assessment above applies regardless of the country; country-specific food data do not change it.

References

  1. Diabetic Ketoacidosis and Related Events in the Canagliflozin Type 2 Diabetes Clinical Program.. Erondu N et al.. Diabetes Care 2015 · PMID 26203064 · DOI 10.2337/dc15-1251
  2. Risk of Diabetic Ketoacidosis after Initiation of an SGLT2 Inhibitor.. Fralick M et al.. N Engl J Med 2017 · PMID 28591538 · DOI 10.1056/NEJMc1701990
  3. Sodium-Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis : A Multicenter Cohort Study.. Douros A et al.. Ann Intern Med 2020 · PMID 32716707 · DOI 10.7326/M20-0289
  4. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition.. Peters AL et al.. Diabetes Care 2015 · PMID 26078479 · DOI 10.2337/dc15-0843
  5. 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026.. American Diabetes Association Professional Practice Committee for Diabetes* . Diabetes Care 2026 · PMID 41358894 · DOI 10.2337/dc26-S006
  6. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy.. Perkovic V et al.. N Engl J Med 2019 · PMID 30990260 · DOI 10.1056/NEJMoa1811744
  7. Sodium-Glucose Cotransporter-2 Inhibitors and Risk of Diabetic Ketoacidosis Among Adults With Type 2 Diabetes: A Systematic Review and Meta-Analysis.. Colacci M et al.. Can J Diabetes 2022 · PMID 34116926 · DOI 10.1016/j.jcjd.2021.04.006
  8. Clinical characteristics and outcomes of diabetes-related ketoacidosis (DKA) in sodium-glucose co-transporter-2 inhibitor (SGLT2i) users with type 2 diabetes.. Sharma A et al.. Diabetes Obes Metab 2025 · PMID 40919651 · DOI 10.1111/dom.70098
  9. Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes.. Wiviott SD et al.. N Engl J Med 2019 · PMID 30415602 · DOI 10.1056/NEJMoa1812389
  10. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials.. Nuffield Department of Population Health Renal Studies Group; SMART-C Consortium. Lancet 2022 · PMID 36351458 · DOI 10.1016/S0140-6736(22)02074-8
  11. Benefits and harms of drug treatment for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials.. Shi Q et al.. BMJ 2023 · PMID 37024129 · DOI 10.1136/bmj-2022-074068
  12. Ketoacidosis at Hypoglycemic and Low Glucose Levels Associated with SGLT2 Inhibitor Use: A Descriptive Systematic Review of Published Cases.. Itagaki H et al.. J Clin Med 2026 · PMID 42882058 · DOI 10.3390/jcm15197595
  13. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes.. Zinman B et al.. N Engl J Med 2015 · PMID 26378978 · DOI 10.1056/NEJMoa1504720
  14. Dapagliflozin in Patients with Chronic Kidney Disease.. Heerspink HJL et al.. N Engl J Med 2020 · PMID 32970396 · DOI 10.1056/NEJMoa2024816
  15. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction.. McMurray JJV et al.. N Engl J Med 2019 · PMID 31535829 · DOI 10.1056/NEJMoa1911303
  16. First-Time Usage of SGLT2 Inhibitors in Patients With Type 2 Diabetes Who Are Fasting Ramadan: Efficacy and Safety.. Khalil HAM et al.. J Diabetes Res 2025 · PMID 40322737 · DOI 10.1155/jdr/4321423
  17. Type 2 diabetes in adults: management (NICE guideline NG28), published 2 December 2015, last updated 18 February 2026. National Institute for Health and Care Excellence (NICE). NICE guideline 2026

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