SGLT2 inhibitors such as dapagliflozin (Forxiga) can cause ketoacidosis, sometimes with normal or low blood glucose.
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
Mostly true – Correct at its core, but with limitations or minor inaccuracies.
Certainty of evidence: moderate – Further research may still affect the assessment.
1. What was claimed?
Forxiga causes ketoacidosis even with normal glucose.
2. What is demonstrably correct?
SGLT2 inhibitors increase DKA risk: HR 2.85 (1.99-4.08) vs DPP-4 inhibitors; incidence 2.03 vs 0.75 per 1,000 person-years; dapagliflozin HR 1.86 (I-ODD-09). In the randomised CREDENCE trial, adjudicated DKA occurred in 11 of 2,200 patients on canagliflozin vs 1 of 2,197 on placebo (2.2 vs 0.2 per 1,000 patient-years; HR 10.80, 1.39-83.65) (I-ODD-05), whereas DAPA-CKD recorded 0 vs 2 cases with dapagliflozin (I-ODD-03), so the risk is rare and population-dependent. Euglycaemic DKA was described in 13 episodes; normal glucose delayed recognition (I-ODD-10). In the canagliflozin programme DKA occurred in 0.07-0.11%, but all cases with glucose values had more than 300 mg/dL, so that programme does not show the euglycaemic form (A-ODD-10). ADA 2026: DKA risk in type 1 diabetes with SGLT2 inhibitors can be 5-17 times higher (I-INS-10). This is why fasting and very low-carbohydrate eating while on SGLT2 inhibitors is risky.
3. What is wrong or exaggerated?
Elawady calls Forxiga one of the 'dirtiest' drugs that 'kills the brain'. DAPA-HF and DAPA-CKD showed that dapagliflozin reduced all-cause death (HR 0.83 and 0.69) and kidney failure (I-ODD-04, I-ODD-03); empagliflozin reduced death by 32% (I-ODD-02).
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-05 (RCT, adjudicated DKA), I-ODD-09, I-ODD-10 (euglycaemic presentation), I-INS-10, A-ODD-10 and A-ODD-11 (DKA with SGLT2 inhibitors; A-ODD-10 cases were not euglycaemic).
6. Which studies contradict it?
I-ODD-02, I-ODD-03, I-ODD-04 (net benefit).
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. The solution is informed use (sick-day rules, ketone testing), not rejection of a drug with proven survival benefit.
Assessment details
- Rationale for certainty of evidence
Consistent signal: case series, trial programme data, a randomised trial with adjudicated events (CREDENCE: 11 vs 1 cases, HR 10.80), a large multinational cohort (HR 2.85 vs DPP-4 inhibitors) and guideline warnings. Absolute risk is low in type 2 diabetes (about 2 per 1,000 person-years in the cohort) and population-dependent (no excess in DAPA-CKD). The euglycaemic element rests on case series. Downgraded from TRUE because the claim is used to argue the drug is net harmful, while RCTs show reduced death and kidney failure.
- 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
- 25 October 2026 provisional
In plain language
Drugs like Forxiga make the body lose sugar in the urine. Rarely, especially during fasting, illness or with too little insulin, this can lead to dangerous acid build-up even when blood sugar looks normal. The risk is about 2 cases per 1,000 users per year. At the same time, these drugs reduce deaths from heart and kidney disease in large trials.
Studies on this claim
Studies supporting the claim (6)
-
Ketoacidosis with canagliflozin
Erondu N et al.. Diabetes Care 2015 · PMID 26203064 · DOI 10.2337/dc15-1251Othercited by the Tayebat archivefull text checkedKetoacidosis 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?
- 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).
-
Ketoacidosis after starting SGLT2 drugs (letter)
Fralick M et al.. N Engl J Med 2017 · PMID 28591538 · DOI 10.1056/NEJMc1701990Cohort studycited by the Tayebat archiveabstract only checkedContent 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.
-
SGLT2 drugs and ketoacidosis
Douros A et al.. Ann Intern Med 2020 · PMID 32716707 · DOI 10.7326/M20-0289Cohort studyindependent cross-checkabstract only checked★ key studyAbout 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?
- 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.
-
Ketoacidosis with normal blood sugar on SGLT2 drugs
Peters AL et al.. Diabetes Care 2015 · PMID 26078479 · DOI 10.2337/dc15-0843Case series / case reportindependent cross-checkfull text checkedSeveral 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?
- 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).
-
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-S006Guideline / position statementindependent cross-checkfull text checked★ key studyMost 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.
-
Canagliflozin in diabetic kidney disease
Perkovic V et al.. N Engl J Med 2019 · PMID 30990260 · DOI 10.1056/NEJMoa1811744Randomised controlled trialindependent cross-checkfull text checked★ key studyKidney 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.
No study in this group is marked as key.
Studies contradicting or limiting the claim (3)
-
Empagliflozin heart trial
Zinman B et al.. N Engl J Med 2015 · PMID 26378978 · DOI 10.1056/NEJMoa1504720Randomised controlled trialindependent cross-checkabstract only checked★ key studyDeaths 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?
- 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.
-
Dapagliflozin (Forxiga) in kidney disease
Heerspink HJL et al.. N Engl J Med 2020 · PMID 32970396 · DOI 10.1056/NEJMoa2024816Randomised controlled trialindependent cross-checkfull text checked★ key studyForxiga 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.
-
Dapagliflozin in heart failure
McMurray JJV et al.. N Engl J Med 2019 · PMID 31535829 · DOI 10.1056/NEJMoa1911303Randomised controlled trialindependent cross-checkabstract only checked★ key studyFewer 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.
No study in this group is marked as key.
Studies with mixed or unclear results (0)
No studies in this group.
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
Mostly true Correct: SGLT2 inhibitors can rarely cause ketoacidosis, which is a reason for care, not evidence that they are net harmful.
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
- 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
- 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
- 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
- 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
- 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
- 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
- Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes.. Zinman B et al.. N Engl J Med 2015 · PMID 26378978 · DOI 10.1056/NEJMoa1504720
- Dapagliflozin in Patients with Chronic Kidney Disease.. Heerspink HJL et al.. N Engl J Med 2020 · PMID 32970396 · DOI 10.1056/NEJMoa2024816
- 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