Type 1 leaning toward stopping Jaridance (SGLT-2)

Quick summary: I’ve been taking Januvia and Jaridance for the last ~18 months since being diagnosed type 1. I’m still in the honeymoon of creating some insulin but I take both basel and bolus insulin daily.

Three days ago I stopped taking Januvia, so far my sugar has been the same or slightly better.

I’m not considering stopping the Jaridance 10mg I take daily.

I’m hoping someone can confirm if this sounds correct to them…
Jaridance on average eliminates 78 grams of sugar per-day via urine.
15 grams of sugar = 1 carb.
So that means Jaridance is only removing about 5 carbs worth of sugar for me? If so that is hardly anything and not worth taking an expensive pill over.

Just curious if that line of thinking sounds correct to others.

Why am I stopping Januvia/Jaridance?

  1. I don’t like medicine in general
  2. Every day multiple times a day I don’t feel awesome and don’t know why
    Mostly I have a slight nauseas feeling on and off every day and it drags down enjoying life.
  3. These are not approved type 1 medications and insulin/exercise/diet is likely all I really need to manage my sugar.

Thank you

Have you checked your urine and serum ketones while on Jardiance and experience not feeling so great? (I thought Jardiance was approved for Type I. I am not sure about Januvia.)

I can’t tell you to stop or start that is up to you. I do know as a type 1 you can be very well controlled without anything other than insulin. Before they diagnosed me right they had me on Januvia and it made me not feel well, A slight dizziness and general stuffy head feeling. It also started giving me horrible leg cramps at night that took months to go away after I stopped it. This was before I was on insulin and every medication they tried on me for a type 2 made me sick, probably because I needed insulin.

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I’ve intermittently checked my ketones over time and always been basically 0 except when I got stomach bug. During that day they were moderate/high.

My understanding was for Europe Jaridance is approved for Type 1 but the US FDA voted not to approve it for now.

My doctor just prescribed it off label. Plus since I’m in the honeymoon and make some insulin he felt some type 2 medications might still help me.

I’m on day 3 no Januvia and no issues and no increase in average blood sugar. For the last 2 days its actually been slightly better then normal. Likely tomorrow I will stop taking the Jaridance and I’m expecting I will notice little to 0 effect on my blood sugar.

Well, I dunno about the math—I’ll trust you for that—but I can describe my own experience. I don’t take Januvia, but I started Jardiance about 18 months ago, and it has had a marked effect on my TDD and A1C. TDD used to run about 70u, now <50, and my last three A1Cs were ~5.8. Marks the first time I’ve been below 6 since I was dx’d 37 years ago.

Note that there’s a titration factor with these drugs—definitely with Jardiance and I assume so with Januvia. That means there’s a lag between starting/stopping the drug and seeing the effects. My understanding with Jardiance is that it’s about five days.

Definitely worth seeing if meds are at fault, so going off them one at a time to limit the variables is a good way to find out. No side effects for me, but YDMV as always.

It seems endos are increasingly inclined to try T2 meds on T1s because they’re seeing notable improvements, as I’ve experienced. “Off-label” doesn’t mean “dangerous,” it just means that it hasn’t undergone formal approval so it’s kind of up to you and your prescriber. I think Metformin is still off-label for T1 but lots of us take it. I started ages ago when I was on MDI because MDI sucks at controlling dawn phenomenon, a big problem for me, and Metformin helped. A pump does even better—you can program in compensation for your DP—but I stayed on it because of my guiding principle with insulin: the less you have to take, the easier it is to control. I’m lucky to have had no noticeable side effects from these off-label drugs, but it’s worth considering that insulin has the worst side effects of all, if you count loss-of-vision-shaking-and-sweating-call-the-EMTs hypos. I haven’t had many, but even one near-death encounter is more than too much.

All that said, though, I think if you’re still in honeymoon, still generating some endogenous insulin helping to keep you stable, and insulin plus diet/exercise can keep you in range, then go with it. It’s always a matter of testing what works for you and what doesn’t, and being able to adjust things as you need to over the long haul, since it is a long haul and things just do change for everyone over time.

@DrBB thanks for the detailed response. If stopping Jaridance caused me to increase my TDD of insulin 20-30% I would probably keep taking it. I do try to limit how much insulin I need by eating less carbs, and walking 45 minutes after eating/taking insulin.

So far I haven’t had any EMT visits for lows I’ve never had a low worse then 48 that I know about. Most commonly they are in the 50’s since the Dexcom alerts me in time to stop it dropping much more then that.

Thanks for sharing your thoughts and experience.

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That’s a good way to go. Exercise is metabolically amazing when it comes to BG. Years ago an endo told me it takes something like 35 chemical steps to get glucose through into a cell when the body’s at rest, and only 1 when you’re exercising. Not sure if that’s perfectly biochemically accurate (memory, sigh) but it conveys the idea pretty strongly.

I’ve found two things to be pretty consistent about using exercise to lower BG: one is that I usually get a bit of a bounce-back from it, so if it puts me into low territory (70s) I try to resist treating for a good 15-20 minutes even if I’m starting to get cravings. Usually it will come back into normal range on its own by then. Do you find that to be true? The other thing is that I’m a bike rider, and whereas that is a great bg-dropper under most circumstances (sometimes TOO good), if the outside temp gets too low it actually knocks my BG UP and I end the ride 20-30 pts higher than when I started. I’m guessing its an adrenal effect like you get when you’re doing very intense exercise as opposed to steady aerobic like cycling. Used to have to be <32° for this to happen, but as years have gone by the temperature limit seems to be rising. 40s now will sometimes do it. Frustrating b/c I like riding in the cold, but I want the BG benefit too.

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That is really interesting note about the 35 vs 1 step to use sugar when excising. I thought I’d read something about when excising your muscles don’t need insulin or maybe it was way less insulin to use glucose in the blood.

Most of the time when I walk/run/bike I do see a small 10-15 point increase when I stop exercising.

I’m in Florida so I’m not sure I get cold enough on a regular basis to see the patterns related to cold.

For more intense run’s or long bike rides I tend to go low and have to carry tablets/Gatorade with me. Partly I think it’s because I do MDI. I often don’t know far enough in advance what I’m going to do to adjust ahead of time. I assume one day if I switch to a pump it will be more flexible in that way.

I’ve only done this a few times but if I go for a long 2+ hour ride I get my self a 20oz coke on my way back and it works out pretty well with my sugar. It’s the only time I’ve had a Coke in the last 18 months so it feels pretty rewarding.

After a good run or bike ride I do notice I’m more insulin sensitive for that day and maybe the next day.

I should I provided this earlier, I’ve seen these numbers quoted in a few places when I search for it.

12.2 Pharmacodynamics

Urinary Glucose Excretion

In patients with type 2 diabetes, urinary glucose excretion increased immediately following a dose of JARDIANCE and was maintained at the end of a 4-week treatment period averaging at approximately 64 grams per day with 10 mg empagliflozin and 78 grams per day with 25 mg JARDIANCE once daily [see Clinical Studies (14)]. Data from single oral doses of empagliflozin in healthy subjects indicate that, on average, the elevation in urinary glucose excretion approaches baseline by about 3 days for the 10 mg and 25 mg doses.

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@ChrisP Lol…a pump does help make exercise easier and also doesn’t help make it easier!!!

It’s sometimes of course easy to do temp reduction of basals or small extra doses, sure. But you still have to figure out what your responses will be in the first place!!!

You need as much insulin as you need. I would low carb if I was having uncontrolled BG spikes, crashes, or overweight. It does help keeping your BG in range

I would research Jardiance more. When you can have normal BG and still have DKA, it blocks seeing the big red flag of trouble.

https://www.pharmacytimes.com/contributor/deepali-dixit-pharmd-bcps/2016/08/understanding-sglt2-inhibitors-diabetic-ketoacidosis-risk

https://www.endocrineweb.com/news/diabetes/15021-whats-behind-fdas-warning-about-diabetic-ketoacidosis-sglt2-inhibitors

I would stop them and focus on getting your basal dose right first and then your I:C bolus ratio.
do the miss a meal basal testing

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Maybe check your ketones during those times you feel bad (or by “intermittently” does that mean you have already done so? - during those specific times?), and then if they’re elevated, that might be an answer. Otherwise, I got nothin’. :slight_smile:

Yes, I think you’re correct in that Jardiance is not technically approved for T1D.

The last thing I’ll relate is that we’ve seen this one patient for the last 3 years. When he was on his own, and prescribed insulin, he probably wasn’t taking it and of course eating poorly, and his BGs were very high as was his A1c, over 12 IIRC. Then, once he was admitted and in for an extended stay, he was placed on metformin, jardiance, and one other and does not need any insulin at all. I’m not saying it’s the end all and be all, I happen not to think so (though it’s quite the favorite anti-diabetic these days). And that gentleman has T2D.

@DrBB @ChrisP [quote=“DrBB, post:8, topic:81683”]
I’ve found two things to be pretty consistent about using exercise to lower BG: one is that I usually get a bit of a bounce-back from it
[/quote]

Late last year, I loaned my retired 670G and CGM to a colleague who is a non-diabetic (no infusion of course…use of pump is the only way to gather the CGM data!!). He does intermittent fasting and keto as well…is in excellent shape and was interested in his BG profile in general. I hooked him up with Tidepool so he could chart his data. He too found that his BG would rise post-exercise. I found this interesting and tried an experiment of my own…knowing the BG lowering effects of aerobic activities (swimming, tennis, etc.) over my 36yrs with T1D, I chose to do an anaerobic activity (weight lifting) while starting with stable CGM readings of 80-90mg/dL.

Results: I saw an initial decline to approximately 75mg/dL…I continued through the workout and stayed steady in the 70s. My previous actions would have had me stop the exercise to treat the impending low and end up with a mediocre workout. In this case, I did not stop and I did not treat the impending low. In fact, I put off my meal as long as possible…over the next couple of hours my BG rose to approximately 150mg/dL.

This is just one experiment on one person…but my T1D response to exercise is not unlike that of a non-diabetic…this is the same as you noted @DrBB.

This effect interested me greatly so I researched this metabolic process. In essence, plasma glucose (BG) is primarily consumed by the brain and involuntary muscles and processes (heart, liver, etc.). The liver function is quite interesting…a good amount of insulin is used by the liver to convert plasma glucose to glycogen (de novo lipogenesis) or “stored glucose”. The muscles do the same…they store glycogen for use when needed and convert to glucose for entry into the metabolic process…hence when exercise is extreme and prolonged (5 hours of tennis!!) the BG can drop for 4-10 hours post exercise…the muscle stores are replenishing their coffers.

Also with extended exercise events, the liver will fuel the body with its stores of glycogen by converting the glycogen to glucose…and conversely after exercise…replenish the glycogen stores via de novo lipogenesis.

For years, I have said that T1D and T2D are more distinct diseases than just “types” of Diabetes Mellitus…this was mostly based on the marked difference of complication rates between T1s vs T2s. Specifically, mine and my grandmother’s experience…she was a “diagnosed” T2 for less than 10 years…in that time frame she had open heart surgery, lost most of her eyesight, lost a leg below the knee and passed away…this seemed to me an extreme progression of events…frankly it was alarming. Me as a T1 of almost 37 years have little to no complications and I still could not reconcile her experiences and my own…until I watched the video below by Dr. Jason Fung…“A New Paradigm of Insulin Resistance”

This has given me a great deal of understanding in the distinct differences between the “types” and how the treatments of T1D and T2D differ metabolically.

Living with T1D for 36+ years I have seen my ratios change dramatically and my insulin needs increase…Carb ratio=1:8; ISF=1:30. Arguably, these look like T2D w/insulin ratios. I am currently around 60u/day on the X2 w/CIQ…your decrease in insulin and A1C w/Jardiance is impressive…they have inspired me to look into some of the SGLT2 inhibitors as adjunct therapy options to my pump.

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Definitely a new type of thinker. It took a while, but I have come to truly appreciate Dr Fung.

They work by lowering the BG level, that the kidneys will pee glucose.
Have you tried low carb to lower your insulin resistance, it also stabilizes your BG
Bernstein’s law of small numbers