Author bio | Disclosures The ever-increasing number of therapeutic interventions has created excitement and enthusiasm in diabetes care. While this wider choice is welcomed by some, it also creates challenges, and increases responsibility of the practicing physician. Diabetes care providers are well versed with drug–drug interactions and their clinical significance. Theresa Smyth, however, highlights a diet–drug interaction that has the potential to be fatal. Sodium glucose cotransporter 2 (SGLT2) inhibitors are now accepted as front-line drugs for the management of type 2 diabetes . Modern treatment guidelines support earlier and more widespread use of these agents, especially for the prevention and management of diabetes complicated by atherosclerotic cardiovascular disease. At the same time, dietary guidelines for the management of diabetes have become less prescriptive in their requirement for specific macronutrient proportions . This has facilitated a resurgence in the use of ketogenic diets, which have been proven to reduce weight and improve glycemic control . SGLT2 inhibitors and ketogenic diets share similarities in their mechanism of action. Both reduce the carbohydrate load in the body (albeit by different mechanisms) and thus de-stress the pancreatic beta cell, by reducing the need for insulin. "Proper patient selection is a must when initiating SGLT2 inhibitor therapy or ketogenic diets." CC0 No Rights Reserved × Proper patient selection is a must when initiating SGLT2 inhibitor therapy or ketogenic diets. Patients at risk for ketoacidosis, including debilitated individuals, must avoid such combinations of treatment. Patients on SGLT2 inhibitor therapy must be informed about the need to maintain adequate carbohydrate intake , and discuss dietary changes with their diabetes care team. The healthcare team should specifically enquire about use of restrictive diets. Warning signals of ketoacidosis must be explained to patients and their caregivers, and the red flags that should prompt contact with healthcare personnel must be clearly mentioned on prescriptions. The astute clinician should be able to monitor and modulate ketone concentrations, to ensure optimal health. Using the principles of good clinical sense and responsible patient-centered care are key to providing a safe and effective treatment. Editors recommendation Case study Acute illness while on a SGLT2 inhibitor and ketogenic diet Advisory Board member Theresa Smyth tackles an emergency case in a type 2 diabetes patient treated with empagliflozin. What went wrong and how should he be managed?