Furthermore, to add to my earlier comment about DKA, the term “euglycemic DKA” is the proper one. It is where (usually) type 1’s exhibit all the symptoms of traditional DKA but without the uncontrolled BG’s. This link details the patients who exhibited this that lead to the Invokana warnings: Euglycemic Diabetic Ketoacidosis With SGLT-2 Inhibitors
In everything Ive read, euglycemic DKA is far more prevalent in type 1’s than type 2’s. Reason being type 2’s generally are producing enough insulin to keep keptones at bay, even when within normal diet-induced ketosis. Type 1’s, of course, dont have that luxury. Here’s another case study of euglycemic DKA: http://jpsionline.com/admin/php/uploads/64_pdf.pdf
The bottom line is, ESPECIALLY for type 1’s on this type of med, to closely monitor ketones. My rule of thumb to balance the risk with the rewards of Jardiance AND incorporating the lowest possible carb diet. is NEVER get above moderate ketones. Thats the “danger zone”. When I hit moderate, I immediately eat a fairly carby meal with my normal bolus. Ketones clear within 6-8 hours. Oh, and lots of water (which I do anyway living in Phoenix).
Thanks @DanP, I’ve been following all this in detail as well. The trouble we have is that the occurrence of euglycemic DKA is associated both with ketones being present as well as dehydration. There isn’t really any evidence that ketones causes the DKA, just as their isn’t any evidence that dehydration cases the DKA. In fact, a hypothesis that dehydration is a cause of DKA is much more likely given that dehydration is known to increase the risk of DKA and that SGTL2 drugs are also known to cause dehydration.
A more detailed examination was a study done by Anne Peters and reported in Diabetes Care. This was a randomized controlled trial which found that SGT2s were “associated” with higher rates of DKA. The study reported that “all serious events occurred in the presence of circumstances that are known to potentially precipitate DKA (e.g., infection, insulin pump failure).” And this study looked at ketone related adverse events including: (i.e., acidosis, blood ketone body increased, blood ketone body present, DKA, diabetic ketoacidotic hyperglycemic coma, ketoacidosis, ketonemia, ketonuria, ketosis, metabolic acidosis, urine ketone body present). But the study only included serious adverse events. The study did not conclude that the presence of ketones bodies was associated with adverse events or DKA. The takeaway is that there appears to be some non-trivial risk associated with SGTL2 in type 1, but the mechanism is not understood.
Personally, I would suggest worrying more about dehydration than ketones. But it is true that if you have uncontrolled diabetes you be careful with SGLTs (as well as lots of other things) as many things may put you at increased DKA risk.
Thanks @Brian_BSC for the link to the study at Diabetes Care. Very good. Yes there is still alot of “fuzziness” in regards to the link between SGTL2 drugs and euglycemic DKA in type 1’s; however, there is still enough evidence for possible causation that I believe T1’s on these drugs should test regularly and be mindful.
Its purely anecdotal, but in my case last year I set out to try an ultra low carb diet for 2 weeks (under 20g/day). I normally drink around 2 litres of water per day, on average. Blood sugars for the first two days were EXCEPTIONAL. In fact, I posted a pic of a 24 hour period in the flatliners club thread of my CGM. Dead flat. After day 2, I started not quite feeling well, and on day 3 I recognized the symptoms…thirst, tired, confused, couldnt keep a thought straight. The beginning of DKA. I tested and sure enough, high ketones. I immediately cooked and ate a full bowl of macoroni and cheese along with a normal bolus. Within 24 hours I felt fine, and ketones back to normal.
Again, anecdotal, but enough for me to pay attention to it.
It is well known that it takes 2-3 weeks to adapt to a low carb diet. During that time you may experience the exact symptoms you describe. It is sometimes called the “Atkins Flu.” The vast majority find the symptoms abate and they have an abundance of energy after that. In the book “The New Atkins for You” the researchers Westman, Phinney and Volek suggest that several cups of bouillon (with sodium) every day can do a lot to quell the symptoms.
And unfortunately there are huge misunderstandings about ketones and ketosis. Ketones when doing a very low carb diet are absolutely normal and they can surge during the 2-3 weeks of adaptation period. I’m sorry it disturbed you at the time.
People with type 1 can and do successfully use ketogenic diet with metabolic ketosis.
I do typically eat very low carb diet - though i am not this week because i am in Germany for work and there seem not to be low carb options available. The breakfast buffet at my hotel has nothing green, though plenty of white (bread!, and Beer halls seem to be a national pastime here - and, i have never been known to abstain when a pint was offered.
Back to topic. I don’t test for ketones. As far as i know there is no test kit available for urine ketones where i live. There is 1 available for blood ketones but too expensive to consider. So ketones are only tested through lab urinalysis.
From my understanding, for dka to occur one needs a number of things to happen all at once: 1. Lack of insulin (this also may occur during illness, when insulin requirement goes up) + dehydration + resulting metabolic disarray which then compounds the situation. High ketones are seen, but these are the result of rather than the cause if the problem. If one can ensure adequate insulin and hydration then all can be ok. If one is sick one must be extra careful. Presence of ketones alone is not an alarm.
It does concern me that this drug can mask inadequate insulin. This would probably be more likely if one was running sugars high (the insert paper talked about studies where patients had a1c of 7.5 or higher to join - so these people were running sugars in the 180s+ - as per ada targets). For further study. I think the biggest risk may be in people wrongly diagnosed as type 2, and having inadequate insulin present.
I personally suspect that running a very right blood sugar in the 70 - 90 range, where relative sugar loss is less (insulin is definitely needed) may lessen the risk.
I am 5 days in on jardiance. After the first 24 - 36 hours with no insulin and low sugars and feeling yucky, i am back taking my regular basal insulin (18 -20 units/day) and sugars are slightly lower (particularly seems to help with darn phenomenon and blunting post eating numbers. Bolus is less but I’m still having to cover Germany carbs - travel also shakes things up.
