Is erythritol safe? New data on the sweetener and blood clots

Erythritol is the sugar alcohol behind much of the "zero-sugar," "keto-friendly" aisle — in sweetener blends, protein bars and low-carb baking. Regulators in the US and European Union treat it as safe, and for blood sugar it is close to inert. But a run of newer studies has put an asterisk on that reassurance: high blood levels of erythritol are associated with cardiovascular events, and feeding it to healthy people makes their platelets more prone to clumping [s1][s2]. The safety signal is real and worth understanding, even though it does not yet prove that eating erythritol causes heart attacks.

What the 2023 study found

The concern traces to a 2023 paper in Nature Medicine. Researchers first ran untargeted metabolomics in 1,157 patients undergoing cardiac risk assessment and noticed that circulating levels of several polyol sweeteners, erythritol most strongly, tracked with the three-year risk of major adverse cardiovascular events — a composite of death, non-fatal heart attack or stroke [s1].

They then checked the finding in two independent groups of stable patients having elective cardiac evaluations. In a US cohort of 2,149 people, those in the highest quartile of blood erythritol had an adjusted hazard ratio of 1.80 for these events versus the lowest quartile (95% confidence interval 1.18 to 2.77) [s1]. In a European cohort of 833 people, the corresponding hazard ratio was 2.21 (95% CI 1.20 to 4.07) [s1]. Roughly a doubling of risk, reproduced on two continents.

Crucially, the team went beyond correlation. At physiological levels, erythritol enhanced platelet reactivity in the test tube and promoted clot formation in animal models [s1]. And in a small pilot, 8 healthy volunteers who ingested erythritol showed marked, sustained increases in plasma erythritol — above the thresholds linked to heightened clotting — lasting more than two days [s1]. The authors' measured conclusion was that studies of erythritol's long-term safety are "warranted" [s1].

The follow-up intervention

Association studies invite the obvious objection: sick people might simply have higher erythritol for other reasons, since the body also makes small amounts internally. A 2024 study in Arteriosclerosis, Thrombosis, and Vascular Biology was built to answer that with a prospective design [s2].

Healthy volunteers, 10 per group, consumed either erythritol or glucose, and the researchers measured platelet function before and after [s2]. A single 30-gram dose of erythritol — the amount in a large sugar-free drink — raised plasma erythritol concentration more than a thousandfold, to 6,480 µmol/L versus 3.75 µmol/L, while 30 grams of glucose did not [s2]. After erythritol, platelets became more reactive across every agonist and dose tested, with greater release of the clot-promoting granule marker serotonin; glucose produced no such effect [s2]. That a controlled dose reproduces the clotting phenotype in healthy people is what lifts the finding above pure correlation.

What this does and does not prove

Two limits keep this honest. The cardiovascular-outcome data are observational, drawn from patients already under cardiac evaluation, so residual confounding cannot be excluded, and the human intervention measured a clotting phenotype over hours, not heart attacks over years [s1][s2]. No randomised trial has yet tested whether cutting erythritol lowers cardiovascular events. Erythritol remains an approved additive, and for people managing blood sugar it still avoids the glucose spikes of sugar — a real benefit that this evidence does not erase.

But the direction of the signal is consistent: an association with events on two continents, a plausible mechanism, and a controlled dose that reproduces the mechanism in healthy volunteers [s1][s2]. That is a stronger evidentiary chain than most single-ingredient scares assemble, and it is specific to erythritol rather than sweeteners as a class — a reminder that "sugar-free" is not a synonym for "consequence-free." For the broader regulatory picture on non-sugar sweeteners, see our piece on what the WHO concluded.

So, is erythritol safe?

The regulatory answer is still yes, and the blood-sugar case for it is intact. But the newer cardiovascular data are a genuine caution rather than a scare: high circulating erythritol is linked to a near-doubling of cardiovascular events in at-risk patients, and a realistic dose measurably increases platelet clotting in healthy people [s1][s2]. Until longer trials settle whether that translates into real-world harm, the reasonable reading is that erythritol is not the risk-free sugar substitute its marketing implies — most relevant for anyone consuming it in large, daily amounts.

This article is informational and is not medical advice.

Sources

• The artificial sweetener erythritol and cardiovascular event risk — Nature Medicine, 2023
• Ingestion of the Non-Nutritive Sweetener Erythritol, but Not Glucose, Enhances Platelet Reactivity and Thrombosis Potential in Healthy Volunteers — Arteriosclerosis, Thrombosis, and Vascular Biology, 2024