Mitigating DKA in Type 1 Diabetes for Safe Use of SGLT Inhibitors Using Dual Continuous Ketone and Glucose Monitoring.

Prior treatment

• Chronic systemic corticosteroids (\>4 consecutive weeks) within 6 months before screening or planned use during the study period.
• Recent myocardial infarction, stroke, hospitalization for unstable angina or heart failure within 3 months prior to screening.

Other illness

• Any form of diabetes other than T1D.
• History of diabetic ketoacidosis within 3 months of screening or 2 or more episodes of DKA within the last year.
• History of multiple (≥ 3 infections) genital mycotic or bacterial infections within 6 months of screening or any history of necrotizing fasciitis.
• Hypotension at screening as defined as, systolic blood pressure \< 90 and diastolic blood pressure \< 60 with symptoms of low blood pressure (confusion, dizziness, lightheadedness, fainting, heart palpitations).
• History of a level 3 hypoglycemic event (as defined by ADA criteria) within 3 months of screening.
• New York Heart Association Class IV heart failure.
• Impairment of systems and organs that may increase their risk of participating in the intervention study or compromise the results (for example: end stage kidney disease, active liver dysfunction, gastroparesis, anemia, organ transplant).
• Active Hepatitis B or C, or tuberculosis.
• History of severe acquired immune deficiency syndrome or human immunodeficiency virus (HIV) infection or severely immunocompromised status, in the opinion of the investigator, including, but not limited to patients who have undergone organ or bone marrow transplantation. HIV positive patients who are on stable immunosuppressive therapy and have undetectable viral load may be eligible for inclusion in the study, subject to the investigator's discretion.
• Current or past history of decompensated cirrhosis (defined as variceal bleeding, ascites or hepatic encephalopathy), and/or known diagnosis of cirrhosis.
• Cancer treatment (excluding non-melanoma skin cancer treated by excision, carcinoma in situ of the cervix or uterus, ductal breast cancer in situ, resected non-metastatic breast or prostate cancer) within one year of screening.
• History of kidney transplant.
• Chronic kidney disease (CKD) from a known cause other than T1D.
• Current or clinically significant history of an eating disorder.
• History of foot amputation.
• Documented medical adhesive allergy, as evaluated by investigator.
• Heavy alcohol use (for men, ≥5 drinks on any day or ≥15 drinks per week; for women, ≥4 drinks on any day or ≥8 drinks per week) at screening, history of alcohol use disorder or binge drinking.
• Any condition or factor that would compromise the participant's safety or conduct of the study (for example: cognitive impairment, bipolar disorder, or eating disorder) or any other reason the PI deems that the patient should not be included.

Lab values

• Any history of use of sodium-glucose cotransporter inhibitors and use of other non-insulin glucose lowering medication within the last 6 months.
• CKD-EPI estimated glomerular filtration rate (eGFR) \<25 mL/min/1.73m2.
• Abnormal liver function at screening defined as any of the following: aspartate aminotransferase (AST) \>2X upper limit of the normal reference range (ULN), ALT \>2X ULN, serum total bilirubin (TB) \>1.5X ULN.

Other

• Pregnant, lactating, or planning to become pregnant or unwillingness to be on contraception during the trial.
• BMI \<22 at time of screening.
• Adherence to a very low carbohydrate or ketogenic diet (\<100g carbohydrate /day) and unwilling to change during study participation.
• Non-healing wounds of extremities.
• Inability to perform the study follow up or unwilling to wear the DGK device.
• Participation in another treatment or intervention study within the past six weeks.

• Provision of signed and dated informed consent form.
• Stated willingness to comply with all study procedures and availability for the duration of the study.
• Males and females; Ages 18-75.
• Diagnosis of type 1 diabetes, based on a clinical diagnosis with onset at least 3 months prior to screening.
• Using an automated insulin delivery system (AID) or multiple daily injections (MDI), (defined by use of rapid analogue with meals and approved long-acting analogue (e.g. detemir or glargine)).
• Most recent eGFR ≥25 (and within prior 12 months).
• HbA1c 7-\<-9%.
• Have never used SGLT2i medications.
• Must be willing and able to wear a DGK device and willing to follow the study protocol.
• Must be able to read and speak English.
• Use of adequate contraception for the duration of the study be the women of childbearing potential.
• Access to necessary resources for participating in a technology-based intervention (i.e., computer, smartphone, internet access).