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Dapagliflozin and ketones

M

MarthaD

Well-Known Member
Messages
54
Location
Edinburgh
Type of diabetes
LADA
Treatment type
Insulin
Hi. I've just started dapagliflozin and have slightly elevated ketones (1.1). Wondering if anyone knows if this is to be expected? I'm being monitored for latent type 1. Glucose levels are good. Thanks.
 
Hi there - any more context - why are you being monitored for Type 1 if your glucose levels are good? can you give us any more details?
 
Sorry, I was clear as mud. I might have LADA. Slim and losing weight. Have had worsening glucose for some time, even when on full dose of Metformin. I don't eat a carby diet, but not low carb either. Latest hba1c is 65mmol/l. My cpeptide isn't low enough yet for insulin. The addition of dapagliflozin has brought my glucose levels into mostly normal range, but have slightly elevated ketones, so I'm wondering if that's normal. This is only day 5 of dapagliflozin.
 
I would be very weary of ketones on a flozin.
Do you have reason to expect ketones because of your diet? Do you eat low carb? Have you fasted or eaten fewer carbs than you usually eat today?

The thing with flozins is that it's possible to develop DKA without the high blood glucose to go with it.
For T1's the advice is to test for ketones to rule out DKA when they have prolonged highs of over 14 or so. But if you don't get the highs you can easily forget that DKA is a possibility if you don't feel well.

www.gov.uk

SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

Test for raised ketones in patients with ketoacidosis symptoms, even if plasma glucose levels are near-normal.
www.gov.uk www.gov.uk
MarthaD said:
My cpeptide isn't low enough yet for insulin.
Click to expand...
As far as I know, there are no T1/LADA guidelines on how low C-peptide should be before starting insulin, usually this decision is guided by blood glucose. There are some who believe that starting insulin early may even help the body produce its own insulin for a bit longer.
But this is about T1, not T2, and you're not sure what type you have yet.
MarthaD said:
The addition of dapagliflozin has brought my glucose levels into mostly normal range, but have slightly elevated ketones, so I'm wondering if that's normal.
Click to expand...
I would contact your HCP with this question, and I would read up on symptoms of DKA as well.
 
Thanks, @Antje77, very helpful. I don't follow a low-carb diet as such, but I'm careful about what I consume and try to limit my carb intake. My endo gave me a prescription for ketone test strips and told me I'd only need to test over 13. Sounds like I need to reconsider that. I think I'll periodically test until I feel more comfortable on the flozin. Back to 0.7 now, so I'll see what happens. Will contact diabetes clinic if they rise again.
 
MarthaD said:
Thanks, @Antje77, very helpful. I don't follow a low-carb diet as such, but I'm careful about what I consume and try to limit my carb intake. My endo gave me a prescription for ketone test strips and told me I'd only need to test over 13. Sounds like I need to reconsider that. I think I'll periodically test until I feel more comfortable on the flozin. Back to 0.7 now, so I'll see what happens. Will contact diabetes clinic if they rise again.
Click to expand...
Makes sense to me. :)
 
My cardiologist wanted to put me on this…. My diabetes team gave me loads of warning that I could get ketones at normal bg levels as the extra sugar just gets pee’d out.

However the raised jetties could be that you are not producing enough insulin OR it could be that you tested after having a low carb meals so it’s normal dietary keytones..

So you need to monitor that those levels don’t rise a level of about is normal for diet keytones.. or that the number is better after a normal meal
 
Thanks for the insight. Spoke to diabetes team. They said to continue to monitor and see if it settles. Meanwhile, get myself to A&E if it goes over 1.5. It's currently fluctuating between 0.7 and 1.2.
 
I’m not a consultant or DSN, and I’m type 1, but…
My consultant will not prescribe “flozins” for patients as they are known to raise ketones at normal glucose levels.
For me, 0.7 would still be high ketones yet that’s the low end that’s being experienced here. I think I would go back and discuss their suitability and the effects with the prescriber. My evidence is obviously just anecdotal but the prescriber should have the information and knowledge at their fingertips.
 
etmsreec said:
I’m not a consultant or DSN, and I’m type 1, but…
My consultant will not prescribe “flozins” for patients as they are known to raise ketones at normal glucose levels.
For me, 0.7 would still be high ketones yet that’s the low end that’s being experienced here. I think I would go back and discuss their suitability and the effects with the prescriber. My evidence is obviously just anecdotal but the prescriber should have the information and knowledge at their fingertips.
Click to expand...

More importantly they are for T2’s only

They should not be prescribed to any form of T1 including lada.. they are not licensed for this use, although they can be prescribed off licensed it should be done with great care
 
searley said:
More importantly they are for T2’s only

They should not be prescribed to any form of T1 including lada.. they are not licensed for this use, although they can be prescribed off licensed it should be done with great care
Click to expand...
Thanks. I've done some reading since, and I'm now questioning why the consultant prescribed them. Doesn't seem to have been a very informed decision. Although he prescribed a ketone meter at the same time, so I'm presuming he must know there are risks.
 
MarthaD said:
Sorry, I was clear as mud. I might have LADA. Slim and losing weight. Have had worsening glucose for some time, even when on full dose of Metformin. I don't eat a carby diet, but not low carb either. Latest hba1c is 65mmol/l. My cpeptide isn't low enough yet for insulin. The addition of dapagliflozin has brought my glucose levels into mostly normal range, but have slightly elevated ketones, so I'm wondering if that's normal. This is only day 5 of dapagliflozin.
Click to expand...

Antje77 said:
I would be very weary of ketones on a flozin.
Do you have reason to expect ketones because of your diet? Do you eat low carb? Have you fasted or eaten fewer carbs than you usually eat today?

The thing with flozins is that it's possible to develop DKA without the high blood glucose to go with it.
For T1's the advice is to test for ketones to rule out DKA when they have prolonged highs of over 14 or so. But if you don't get the highs you can easily forget that DKA is a possibility if you don't feel well.

www.gov.uk

SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

Test for raised ketones in patients with ketoacidosis symptoms, even if plasma glucose levels are near-normal.
www.gov.uk www.gov.uk

As far as I know, there are no T1/LADA guidelines on how low C-peptide should be before starting insulin, usually this decision is guided by blood glucose. There are some who believe that starting insulin early may even help the body produce its own insulin for a bit longer.
But this is about T1, not T2, and you're not sure what type you have yet.

I would contact your HCP with this question, and I would read up on symptoms of DKA as well.
Click to expand...
Im type 2 and in insuling as well, Yes, you have to be careful having low carbs or keto diet with this medication. I had very high ketones while I'm doing keto diet and been to hospital for one day. My ketones was 6.00 in blood ketones. I admit to myself, I was very stupid to miss this thing, I thought I was doing alright because my BS was always in the range 6-8 mmol....Now I am on moderate carbs as advised by my DN, I am doing between 90 and 120 mg per day as per this advice. But that's too much for me....I am doing must be around 70 mg per day, as of now, no high ketones for me...so you just have to monitor your ketones when you are lowering your carbs....for me, minimum 70g is okay. Its work for me but it might not work for you.....the only thing is I did gain weight, low carbs or keto help me lose weight. But I am doing calories deficit and starting to lose weight again.

My advice..... don't go to keto or very low carb diet...go for moderate carb...90 to 130 is safe....for me, around 70 doesn't develop any ketone (urine test). But expect your sugar will not be the same when you do a keto or low-carb diet. Expect there will be a spike....anyway...I am on insulin as well, so this helps me lower the spike.

Discuss always with your DN
 
No advice except what others have given, as the risks exist and should be taken note of, but a bit of Real-Life experience.
I was put on Dapa for heart problems while in hospital. Typical of hospital care, I wasn't told about the meds change - oooh a new pill, what's that about then -Those are your pills, take them - and they knew I was on a keto diet but I don't think they knew what a keto diet was. They knew I was T2 diabetic, but didn't seem to know anything about that either, except for testing my BG often at the most inappropriate times.I was discharged in due time, and, being me, read the leaflet that came with the Dapa, and thought there might be a problem. Asked my GP who is good, and was totally unconcerned. By then I had been on Dapa and eating keto for four months. Now it's six months, and no issue - I seem to be tolerating the Dapa well with a keto diet. Not saying we should disregard the risks, just adding more info. I am staying alert to possibilities.
 
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