Durable Insulin-free Remission in A-β+ Ketosis-Prone Diabetes With SGLT2 Inhibition: A Case Report With Longitudinal C-Peptide and CGM Data
Abstract
Ketosis-prone diabetes (KPD) is a heterogeneous diabetes phenotype in which some patients with preserved β-cell function can achieve insulin independence after diabetic ketoacidosis (DKA). The role of sodium-glucose cotransporter 2 (SGLT2) inhibitors in maintaining remission in A-β+ KPD remains uncertain because of concerns regarding ketoacidosis risk. We report the case of a 45-year-old man who presented with severe DKA and was classified as A-β+ KPD based on negative islet autoantibodies and preserved C-peptide secretion. Following acute management, structured insulin withdrawal was performed, and dapagliflozin was initiated at week 4 with intensive metabolic monitoring. Over 12 months, the patient achieved sustained insulin-free remission, with significant improvements in HbA1c (12.1% to 6.4%), robust recovery of stimulated C-peptide (peak 4.8 ng/mL), and a continuous glucose monitoring (CGM) time-in-range of 82%, without recurrence of ketosis. This case suggests that in carefully selected A-β+ KPD patients with preserved β-cell reserve, SGLT2 inhibition may be safely integrated into the remission phase under close surveillance. However, these findings are hypothesis-generating, and the contribution of dapagliflozin to remission cannot be determined from a single uncontrolled observation. Prospective studies are required before this strategy can be recommended for routine use.
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