93 year old T2, empagliflozin, low carb and alcohol

[EllieM]

I am investigating empagliflozin on behalf of my T2 father, who is currently low carbing (50g to 90g a day) on metformin with a recent hba1c of 53 (down from 60ish before he got moved to metformin). He's been T2 for about 15 years, on gliclazide before he started to low carb. He's on a heap of other meds for various conditions, most concerning being heart ones.

His DN is recommending it for heart benefits (and kidney benefits ???), not so much hba1c because his current levels are fine given his age.

I have 3 main concerns about it

1) how much of an issue is euglycemic DKA if you are low carb rather than keto? I am finding it hard to google any figures.
2) how much of an issue is it that he drinks a lot of alcohol? ( He's not going to stop drinking at 93.)
3) Are urine infections much of an issue for males on this drug? (Bearing in mind that most of his liquid intake is coffee or some form of alcohol).

My brother is going to email his doctor/DN with our concerns and obviously I appreciate that you can't give medical advice, but am concerned that the DN probably hasn't considered his alcohol consumption or his diet.

Comments and useful links welcomed.

Thanks everyone.

 

[HSSS]

Can’t answer specifically but I’d have the same concerns. The only figures I’ve seem re euDKA are advising the standard 130g of carbs but honestly couldn’t tell you where I saw that.

 

[Oldvatr]

You have probably already read my journey on dapagliflozin, which is slightly stronger than empagliflozin. I have recently reported having a close call with euDKA on this med, where my ketones rose to 8 mmol/l which is high considering my Low Carb is not at the ketogenic level and I was not fasting. I hydrated rapidly, and the levels fell back to low, so I avoided DKA. But it was unexpected, and worrying. It seems that I was suffering an infection at the time, but dehydration is a probable contributor and hydration helps to lower the risk.

Advice? Get him a pot of ketone test strips (preferably for use in BGL meter, but urine strips if no meter capability. Make sure he is hydrated, alcohol and the extra excretion from the med will increase fluid loss.

Is he on a diuretic for his heart? i have reduced my diuretic since it ws depleting my sodium and increasing my potassium levels. Also increased fluid loss.

i have also had the UTI issues, and one time required heavy duty antibiotic administration to clear up one particularly nasty one tht got to my bladder. as a male, the application of anti thrush cream topically is not very effective.

Make sure he checks his undercarriage in the are between the scrotum and the anus. I had to stop my dapagliflozin when i got ulcers in that area that can turn gangrenous due to the sugar spills in tht area. It it the male form of nappy rash, but can go septic since the sugar feeds yeast infectiins such as Candida albicans.

We often treat UTI as an incidental annoyance, but in reality they can move up to the bladder, and also attack the kidneys if not dealt with properly. they are actually quite damaging if not controlled. sadly the patient leaflet and doctors advice for these meds omits these possibilities. Having had near experiences myself, I think they may be more prevalent than we are advised, and my GP refused to send in any yellow cards when I requested it presumably because the treatment was susccessful in my case.

 

[EllieM]

Advice? Get him a pot of ketone test strips (preferably for use in BGL meter, but urine strips if no meter capability. Make sure he is hydrated, alcohol and the extra excretion from the med will increase fluid loss.

I've already suggested a pot of ketostix but his fine motor control is poor and I don't think he'd be able to use them. (He's fine mentally but his mobility is poor.) Though he used a meter when he first went low carb he now relies on hba1c so I can't see him being enthused about blood testing for ketones....

To be honest, I'm starting to think this drug might not be for him. Are their stats on how effective it is at preventing heart attacks?

 

[Resurgam]

Am I right in assuming that the low carbing is fairly recent?
When I began to eat low carb every day after being diagnosed type 2 and ignored the GP's diet printout I saw and felt a lot of difference in my well being.
Your father might find that it is the low carb diet, not another medication which is going to make changes, as it is a really powerful boost to the metabolism for many people.

 

[Oldvatr]

i saw a claim by the manufacturer that it was a 38% reduction in risk. Looking at the trial report it was clear that this was relative risk, so the actual benefit is more likely to be about 3% at best. and this was the chance of death, not of events with non fatal outcomes By death I think this is a death on the operating table or on admission , not a month or so later. remember that risk is stated as a single value but the timescale is not declared, and is generally considered to be through life. I always thought the risk of death to be close to 100% for most people.

Apparently the med offers heart benefit since it alters the hematocrit value of the blood. I.e. it changes the red/white cell ratio. Note that this also affects most bgl meters and skews their readings, so maybe this is skewing the claims for bgl lowering

Note the trial noted that Empagliflozin increased both HDL and LDL thus raising TC significantly. Easily solved by adding a statin into the mediwallet.

 

[EllieM]

Am I right in assuming that the low carbing is fairly recent?
When I began to eat low carb every day after being diagnosed type 2 and ignored the GP's diet printout I saw and felt a lot of difference in my well being.
Your father might find that it is the low carb diet, not another medication which is going to make changes, as it is a really powerful boost to the metabolism for many people.

No he's been low carbing for several years now, the metformin is recentish. The empagliflozin would be taken for the heart benefits rather than the blood sugar benefits, as low carb plus metformin is keeping him low enough.

 

[EllieM]

i saw a claim by the manufacturer that it was a 38% reduction in risk. Looking at the trial report it was clear that this was relative risk, so the actual benefit is more likely to be about 3% at best. and this was the chance of death, not of events with non fatal outcomes By death I think this is a death on the operating table or on admission , not a month or so later. remember that risk is stated as a single value but the timescale is not declared, and is generally considered to be through life. I always thought the risk of death to be close to 100% for most people.

I think his current risk of dying just due to age is about 25% a year, and I guess that a heart attack is most likely.... But without a time scale that 38% is fairly uninformative.... I'd want to see a study which included some nonagenarians....

 

[Antje77]

His DN is recommending it for heart benefits

I'd ask a cardiologist, not a diabetes nurse.

 

[Oldvatr]

I think his current risk of dying just due to age is about 25% a year, and I guess that a heart attack is most likely.... But without a time scale that 38% is fairly uninformative.... I'd want to see a study which included some nonagenarians....

I think the way of looking at the risk reduction effect is
in 2021 the death rate fom heart attack was 259 per 100,000 people in the UK. i.e. 0.259%
So the reduction of 38% would mean 0.098% will not die that year if they take empagliflozin.
So of 1000 people taking Empagliflozin, one of them will be lucky and may survive for another year.
so the number to treat seems to be 1000 each year.

 

[Oldvatr]

I'd ask a cardiologist, not a diabetes nurse.

if the heart consultant has prescribed it, then the GP is unlikely to be able or want to stop it. It just isn;t done in polite society. The consultant is senior to the GP who is only a subcontracted worker in the NHS.

 

[AndBreathe]

@EllieM I just watched a video presentation by Ben Bickman from this year's PHC Conferece.

During it, he goes through a bit of a whistle-stop tour of common T2 meds. If not necessarily the whole presentation, that section would be an investment in time. I've just pulled the video timeline along and that part seems to start around the 29 minute mark.

 

[EllieM]

I'd ask a cardiologist, not a diabetes nurse.

Probably true, but I don't think he's going to want to bother to see a cardiologist. He's very much into his last few years, is older than any of his immediate family when they died and his body is pretty worn out. It would be awesome if he could make it to 100 but realistically that's not that likely (though by no means impossible).

I suspect that the DN or doctor have just looked at the NICE protocols and my dad's age and ( longish term) heart issues (stent plus mini strokes that are prevented by blood thinners) and thought this is probably a good idea. I doubt they have considered his alcohol consumption or his diet.

Looks like the latest NICE protocols are here

Overview | Empagliflozin for treating chronic heart failure with reduced ejection fraction | Guidance | NICE

www.nice.org.uk

and new ones are being published in November.

Not even sure whether he has "reduced ejection function" (is this something gps test for?) though he is on a number of heart and blood pressure drugs.

if the heart consultant has prescribed it, then the GP is unlikely to be able or want to stop it. It just isn;t done in polite society. The consultant is senior to the GP who is only a subcontracted worker in the NHS.

I doubt this is coming from a heart consultant but I guess this is something my brother can ask when he emails the surgery...

 

[Antje77]

The thing is, I think it's very odd for a diabetes nurse to prescribe/suggest a medication solely for heart health when it's not for diabetes purposes. I would trust this advice about as much as I would if an asthma nurse told me to take x medication for a broken leg. There is no direct connection in the education they had unless this diabetes nurse is also a cardiology nurse, which is possible.

( longish term) heart issues (stent plus mini strokes that are prevented by blood thinners)

Is this followed up by his GP or a cardiology team? I think the one who oversees his heart medication would be the one to ask.

Probably true, but I don't think he's going to want to bother to see a cardiologist. He's very much into his last few years, is older than any of his immediate family when they died and his body is pretty worn out. It would be awesome if he could make it to 100 but realistically that's not that likely (though by no means impossible).

Is he interested in more medication, especially medication aimed at overall risk reduction and not aimed at treating a specific ailment?

 

[EllieM]

Is he interested in more medication, especially medication aimed at overall risk reduction and not aimed at treating a specific ailment?

I don't think so, but is willing to take it if it's going to benefit him. I think my brother needs to push the surgery to find out exactly why they are recommending this drug, given they are happy with his current hba1c. Other things being equal he's prefer not to take more drugs.

 

[Oldvatr]

The usual test for reduced EF is a doppler ultrasound scan. Normally done in a hospital by the XRAY team.