SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

[Carlwhallinon]

Just started these , what positive changes can I expect to see

 

[SMS1]

hello, I'm on Xigduo ,metformin with dapalgliflozin 5mg/850 mg 2x daily. I was down to 6.1% but back up to 6.9% in my last HbA1c blood test( blip) . I'm extremely dehydrated-my skin is wrinkling on my body and face just recently( I know, I'm 58 ) but even more everyday now despite my hydrating and I sweat at night (but this could due to a supplement i'm taking) ..I'm drinking 2 litres of water, electrolytes everyday and am on low carb just recently due to the recent BT numbers.I've read on this site that SGLT2's and low carb do not go . I have an appointment with endocrinologist in 3 weeks( can't get one earlier) but would like to do something now..I don't want to go into ketoacidosis.I have to go to chemists here to get ketones strips:I hope they have them here(am in Spain),Should I reduce medication or add more carbs?Thanks

 

[Oldvatr]

I have not seen any defnite evidence that LC diets are harmful when used with SGLT2. The only proper evidence I found is:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971428/

Note that the patient was starting a "very strict LC diet" and was only 6 days into the diet when the event occurred. The important thing I note from this study is that the patient was actually a Type 1 diabetic, so the SGLT2 medicine was not appropriate anyway.

There have been other reports that link SGLT2 euDKA events with T1D as shown by FDA advisories, but it seems to be the SGLT2 inhibitor that induces the DKA, not the low carb.

The other point is that LC diets lower BGL as does the SGLT2 inhinbitors in parallel. So it may become necessary to adjust the medication dose as the LC diet takes control. This is normal for any bgl lowering medication used during Low Carb (speaking as a T2) but can apply to insulin doses too, but under medical supervision

 

[SMS1]

I have not seen any defnite evidence that LC diets are harmful when used with SGLT2. The only proper evidence I found is:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6971428/

Note that the patient was starting a "very strict LC diet" and was only 6 days into the diet when the event occurred. The important thing I note from this study is that the patient was actually a Type 1 diabetic, so the SGLT2 medicine was not appropriate anyway.

There have been other reports that link SGLT2 euDKA events with T1D as shown by FDA advisories, but it seems to be the SGLT2 inhibitor that induces the DKA, not the low carb.

The other point is that LC diets lower BGL as does the SGLT2 inhinbitors in parallel. So it may become necessary to adjust the medication dose as the LC diet takes control. This is normal for any bgl lowering medication used during Low Carb (speaking as a T2) but can apply to insulin doses too, but under medical supervision

Thanks, I read your NCBI link. Very informative on this . I can't get to my endo. so will stop the LCD for now even though I would like to reduce my weight,lower BG and medication .As you say, reduce " medication under medical supervison". I hope stopping the LCD now halts the extreme dehydration:If not, it's to the GP.Thanks again.

This is the linkI found on this site :
https://asweetlife.org/a-low-carb-diet-and-sglt2-inhibitors-can-be-dangerous-together/

 

[Oldvatr]

In the article you posted, the author is himself a T1D, and is writing it from the T1D aspect only. But it does raise a couple of new problems that I was only vaguely aware of. Firstly, it is fairly common for GP's to start a new diagnosis by assuming T2D and treat as such until it becomes more apparent from symptoms that the patient has a different form of diabetes or is becoming insulin dependent. This is how NICE guidelines progress in their flowchart. Since the drug companies are pushing this medication as a replacement for Metformin and as a 'cure' for many other common ailments, then they are becoming pressured to prescribe it from the getgo. NICE and the BFN do not carry any warning about mixing it with LC or Low Cal diets, and do not really give proper advice on the euDKA variant (which occurs with 'normal'' glucose levels) So the patients will largely be unaware of these risks, and the A&E staff may also miss the warning signs too.

Second problem is that SGLT2 inhibitors cause raised ketones in the blood but drop the levels in the urine so the wee sticks become useless at giving warnings or sugar levels. SGLT2 meds also apparently reduce sensitivity to hypo's which is also a worry for insulin users. Note: the SGLT2 actually stop the kidneys filtering out the ketones so they build up in the blood unless you burn them off - The dietary levels of ketones is low (less than 4 mmol/l even on full keto) But on an SGLT2 you will also be blocking the removal of ketones from exercise and other normal activities so unless your bgl is low enough for fat burning all the time, this buildup can occur at bgl levels around 10mmol/l rather than the usual >25mmol/l of a standard diabetic DKA

Personally if it was me I would want to avoid this family of medicines since I value my gonads and hate UTI but find low carb an easier alternative for both bgl, BP, and weight control.

 

[SMS1]

Thanks @Oldvatr . I went to an endo. who prescribed me the Xigduo because diabetes is a metabolic syndrome ( I have T2) and IMHO, needs a specialist .I don't know how it works with endocrinologists around the world but GP's are doing what they can with what we know about diabetes-they're all professionals who have information from all sorts of areas as well as the drug companies.It's just I like going to the specialists as well. He will know if I ask him about another medication option due to what you've written here about these inhibitors.Thank goodness for internet sites and forums like these though.

 

[Oldvatr]

Thanks @Oldvatr . I went to an endo. who prescribed me the Xigduo because diabetes is a metabolic syndrome ( I have T2) and IMHO, needs a specialist .I don't know how it works with endocrinologists around the world but GP's are doing what they can with what we know about diabetes-they're all professionals who have information from all sorts of areas as well as the drug companies.It's just I like going to the specialists as well. He will know if I ask him about another medication option due to what you've written here about these inhibitors.Thank goodness for internet sites and forums like these though.

Xigduo is a combi drug of Dapa and Metformin combined, so reducing the dose is not a simple matter. Both are available separately which would allow you to adjust doses. There are other meds around that also reduce glucose by different methods. I am just a bit twitchy about these SGLT2 ones since they seem to have more hidden surprises than most and while in the USA the FDA gives warnings about them, our NICE people seem to ignore any negative aspects and do not even give the GP's advisories. GP's do not have the time to update their knowledge base from the internet, and they are strongly discouraged against doing so by their regulatory bodies. So they prescribe according to a set of rigid guidelines enforced through NICE.

Here the endos are attached to the main hospitals and universities, and deal with metabolic disorders like thyroids and metabolism. Diabetes is not really what they cover, but some become Consultants or Specialists and sit in the Holy of Holies. You need a special referral to see one, and generally T2D and Newbies do not get to see one. I have been 30 years in the saddle of T2 and have never met one.

 

[SMS1]

Xigduo is a combi drug of Dapa and Metformin combined, so reducing the dose is not a simple matter. Both are available separately which would allow you to adjust doses. There are other meds around that also reduce glucose by different methods. I am just a bit twitchy about these SGLT2 ones since they seem to have more hidden surprises than most and while in the USA the FDA gives warnings about them, our NICE people seem to ignore any negative aspects and do not even give the GP's advisories. GP's do not have the time to update their knowledge base from the internet, and they are strongly discouraged against doing so by their regulatory bodies. So they prescribe according to a set of rigid guidelines enforced through NICE.

Here the endos are attached to the main hospitals and universities, and deal with metabolic disorders like thyroids and metabolism. Diabetes is not really what they cover, but some become Consultants or Specialists and sit in the Holy of Holies. You need a special referral to see one, and generally T2D and Newbies do not get to see one. I have been 30 years in the saddle of T2 and have never met one.

I didn’t know that about endo’s( I don’t know where you’re based but NICE and this site’s address suggests the UK). I thought since it’s such a prevalent disease with a lot of the population , there would be more endocrinologist access or at least, a choice to do so privately but I suppose that it’s costly. I didn’t know one had to have a referral too.

 

[nettyrim]

I'm currently in hospital after a DKA episode and have been on forziga for awhile. I have also been fasting and low carbing for awhile and have told my gp thats what I was doing with no information about risks or that I should stop taking it if you are ill. I started with naseau on Tuesday and didnt really eat much all week. Ended up in a and e on Friday afternoon. I dread to think what would have happened if my husband hadnt noticed I was confused before he went to work. One of the consultants knew about forziga and dka but several didnt. I have been taken off them but did wonder if these incidents get reported. I was worried why it had happened so glad to know it was probably the drug.

 

[Oldvatr]

I didn’t know that about endo’s( I don’t know where you’re based but NICE and this site’s address suggests the UK). I thought since it’s such a prevalent disease with a lot of the population , there would be more endocrinologist access or at least, a choice to do so privately but I suppose that it’s costly. I didn’t know one had to have a referral too.

In my county there are acouple of private health endo's. And two main hospitals with an endo dept. I was in one last year for something or other not diabetes related, and I asked to see one because I was being told to keep my sugar levels between 10 and 16, and the ward staff panicked when I was getting between 5 and 8 (on hospital food) and they considered below 8 to be hypoland. I did not get an endo, but did see the Consultant, and we had a good old ding dong about Low Carb (which I won!) and at the same time I refused Dapagliflozin to replace my gliclazide. Again I won out, but it was clear that the Consultant and the doctors on the ward only knew about T1D and assumed T2 would be treated the same. I had my computer on the ward, and shared with them 5 years of Low Carb dieting and testing, and although none of them converted, they did declare me to be technically in remission. That reputation got knocked to a cocked hat when I had the actual operation which put me onto insulin pump for a while. I have not seen a GP or Specialist since about my diabetes, but I am having my annual MOT checkup bloods tomorrow. I so not consider myself in remission but I am happy with where I am.

 

[SMS1]

In my county there are acouple of private health endo's. And two main hospitals with an endo dept. I was in one last year for something or other not diabetes related, and I asked to see one because I was being told to keep my sugar levels between 10 and 16, and the ward staff panicked when I was getting between 5 and 8 (on hospital food) and they considered below 8 to be hypoland. I did not get an endo, but did see the Consultant, and we had a good old ding dong about Low Carb (which I won!) and at the same time I refused Dapagliflozin to replace my gliclazide. Again I won out, but it was clear that the Consultant and the doctors on the ward only knew about T1D and assumed T2 would be treated the same. I had my computer on the ward, and shared with them 5 years of Low Carb dieting and testing, and although none of them converted, they did declare me to be technically in remission. That reputation got knocked to a cocked hat when I had the actual operation which put me onto insulin pump for a while. I have not seen a GP or Specialist since about my diabetes, but I am having my annual MOT checkup bloods tomorrow. I so not consider myself in remission but I am happy with where I am.

I’ll look up gliclazide and ask endo. Thanks again.I’m early days ( if that makes a difference)so I would like to see if I can “reverse” aka get back to some sort of normal blood sugar level. Good luck for tomorrow .

 

[Oldvatr]

I’ll look up gliclazide and ask endo. Thanks again.I’m early days ( if that makes a difference)so I would like to see if I can “reverse” aka get back to some sort of normal blood sugar level. Good luck for tomorrow .

Thank you for that. Glic is fairly benign and has some heart and CVD benefits like Metforin, but there are a few things to be aware before discussing it with Doc. It is a Sylphonylurea drug, and the early onse gainrd a reputaio for caning th pancreas possibly leading to burnout. Glic is a modern update on the drug family, and so far it seems it does not give that problem, but is the only one in the family that has the brownie point. This came out in my discussion in the Hospital where I was able to find evidence in support. Mu consultant found the same report unaided by me, which pleased them no end, so there was no further arguments on that score. Nonetheless, I would suggest keeping it to a lowish dose, which Low Carb will help with.

Secondly, Glic is listed by DVLA as a drug that can drive you to hypoland and back, so they need you to check you sugars before engaging gear. In fact, the Docs should be able to support you self testing and supply test strips on scrip to meet this requirement. My GP does. Keep a log of bgl test results and show it to them at review time to show you are getting good low results. (assuming you do, that is)

I am happy with Glic with Metformin as it allows me to have a lowish carb diet without needing keto, and I can eat some small amounts of carby treats without blowing the bank. My HbA1c over the last 4 years have all come in around 42 or 44 and LC is one lifestyle I can maintain without too much sweat or angst.

Lastly, the hypos from Glic when they occur tend to be fairly mild and short lived providing you are producing your own internal insulin (you would not be on Glic if you weren't, anyway) Glic has a short half life of about an hour, then your liver should have compensated by upping the glucose again. But I find my 40mg tab can drop my bgl by about 4 mmol/l

 

[ringi]

hello, I'm on Xigduo ,metformin with dapalgliflozin 5mg/850 mg 2x daily. I was down to 6.1% but back up to 6.9% in my last HbA1c blood test( blip) . I'm extremely dehydrated-my skin is wrinkling on my body and face just recently( I know, I'm 58 ) but even more everyday now despite my hydrating and I sweat at night (but this could due to a supplement i'm taking) ..I'm drinking 2 litres of water, electrolytes everyday and am on low carb just recently due to the recent BT numbers.I've read on this site that SGLT2's and low carb do not go . I have an appointment with endocrinologist in 3 weeks( can't get one earlier) but would like to do something now..I don't want to go into ketoacidosis.I have to go to chemists here to get ketones strips:I hope they have them here(am in Spain),Should I reduce medication or add more carbs?Thanks

"extremely dehydrated increases the risk of DKA, but skin is wrinkling etc may not be a sign of dehydration. SGLT2's combined with dehydrated is not a good combination!

"extremely dehydrated" is a symptom of type1 diabetes but also can have other reasons.

Try adding more salt to your food as well as the electrolytes.

Have you lost more weight then expected resently?

When did the dehydrated start?

Has BG got worce recently?

In the UK I would be saying see your GP without delay.

 

[SMS1]

"extremely dehydrated increases the risk of DKA, but skin is wrinkling etc may not be a sign of dehydration. SGLT2's combined with dehydrated is not a good combination!

"extremely dehydrated" is a symptom of type1 diabetes but also can have other reasons.

Try adding more salt to your food as well as the electrolytes.

Have you lost more weight then expected resently?

When did the dehydrated start?

Has BG got worce recently?

In the UK I would be saying see your GP without delay.

@ringi Yes it could be age or I’m T1 (or something other- hopefully not) but not such severe dehydration in 4.5 days. ....it happened in the past few days I noticed it. Since I’m new to this, I just bought a blood glucose meter(Accucheck) that’s all they had at chemists.I’m drinking electrolytes, 8 oz water every 30 mins and will add more salt now. It seems caffeine doesn’t help at all- saw a marked difference after having a coffee. Will see a GP. Thanks .I read about ketones building up in blood with this inhibitor (thanks to Oldvatr) which cannot be tested in urine( at least to my understanding ).One thing, I was taking sertraline and due to what was written by a poster on this site about increasing bg ,I’ve stopped taking it until I see what’s happening with this. Thanks.

 

[Oldvatr]

New report on SGLT-2 meds that they may cause low sodium levels;
https://acutecaretesting.org/en/jou...a-caused-by-diabetes-drug-a-case-study-report

The case study is for Empagliflozin, but is probably a class effect,

I do not recognise this site, so cannot claim it to be reliable. It has not made it to the FDA watch list yet.