Feeling a little confused...

Stephyr7783 said:

Hi all,
Been a type 2 diabetic for a number of years always on oral anti hyperglycaemic meds, anyhow I was recently started on lantus, to take along side Dapagliflozin, about 3 days after I had a random high BM and decided to test for ketones (not something I would ever normally do) and low and behold my ketones were high, fast forward a few days and I was released from hospital following treatment for euglycemic DKA. Now to my quandary..I would like to eat low carb to try and get better control over blood sugar levels and general health but I’m a bit worried about having no carbs and getting another DKA. Has anyone an idea of how many carbs per day or meal I should be aiming for to keep the happy medium of not being in danger of another DKA but not eating loads of carbs and struggling to get blood sugar levels under control. I’m currently taking 24u lantus and 12/14 units of novorapid.
Thanks

Click to expand...

DKA only happens if your ketones AND your blood sugars are high. If you are in nutritional ketosis, which is usually reached at about 30 to 20 grams of carbs total a day, and burning fats and protein for energy instead, you should be fine, as that'd mean your blood sugar levels are low... When your blood sugars are high though, your body starts eating itself for energy, which releases ketones too. That's the dangerous kind of ketosis to be in.

First, if I were you, I'd check with my medical team. You're on a LOT of blood glucose lowering medication. What's the reason for that, do you know or do you need to get tested (Homa-IR I think the test was?)? Are you extremely insulin resistant and still make your own but can't use it? Or has your pancreas gotten to the point of exhaustion, and doesn't it make any anymore? Because while a low carb diet can help calm down erratic blood sugar spikes and whatnot, even when someone produces little to no insulin, if you don't make insulin yourself, it might not be enough. And if you do still make your own insulin and you go very low carb, or even keto, well... Hypo's would in all likelihood occur, with the regime you're on. So whatever you do, do it carefully.

So.... If you are on a very carb heavy diet, just taper it off little by little.... Don't go from 300 grams of carbs a day, for instance, to 20. It'd shock your system and would be extremely out of pace with your medication, and odds are you'd face-plant. Just take it easy, very carefully, and lower while testing your heart out. You might need to lower your medication intake as well as your insulin levels though, and I don't know how comfortable you are doing that in a time where getting hold of medical advice seems... Kind of like jumping through burning hoops. (Thank you, Covid!).

If you're worried about hitting nutritional ketosis, just stay at 50 grams a day, no less, that should keep you from entering ketosis. I am just worried about the insulin in this combination, and honestly.... DKA doesn't happen often to T2's, not unless there's an infection or medication involved, from what I understand. I'm a little surprised they didn't run GAD and C-Peptide tests while you were in the hospital. You wouldn't be the first person diagnosed with T2, when they're really LADA/T1. (And yes, there are people here who were misdiagnosed as T2 for years here.). I'd make finding out my type for 100% sure a point, before diving into the diet, really.

Good luck, stay safe!
Jo

Stephyr7783 said:

Thanks for the advice Jo, I meant to add I am no longer on the Dapagliflozin as they attributed that medication to the occurance of the DKA.
I had the tests to confirm I was defintely a type 2 prior to commencing the Lantus and the consultant is convinced I’m type 2 as was the hospital consultant.
I seems like a lot of type 2 diabetes treatment is trial and error, and I completely understand why that is but it’s doing my nerves no favours.

Click to expand...

DKA is a reported side effect of Dapaliflozin


https://bnf.nice.org.uk/drug/dapagliflozin.html

If you are going to try low carb then be prepared to not need your insulin.
Talk to your HCP's maybe before trying this unless you are very confident in managing your inulin use as the last thing you want are hypos. As you are on fixed insulin doses it's very important that you get some input from them.

Stephyr7783 said:

Thanks for the advice Jo, I meant to add I am no longer on the Dapagliflozin as they attributed that medication to the occurance of the DKA.
I had the tests to confirm I was defintely a type 2 prior to commencing the Lantus and the consultant is convinced I’m type 2 as was the hospital consultant.
I seems like a lot of type 2 diabetes treatment is trial and error, and I completely understand why that is but it’s doing my nerves no favours.

Click to expand...

Did they check whether you still make insulin? T2's usually start off making loads and being insensitive to it, but eventually production can taper off. Do you know whether you still make it?

With the probable cause of the DKA identified, I think, maaaybe, you can just start trying to cut some carbs... If you are confident you can adjust your insulin and such without running into trouble. (Also known as, stock up on stips or get yourself a continuous glucose monitor for a few weeks at least). Like I said, DKA doesn't usually happen without something else in the mix, and with the Dapa gone.... Odds are it probably won't happen again. If you want to avoid nutritional ketosis to be on the safe side, just stay at 50 grams of carbs a day or over. And take the cutting down slow. As for a lot of T2 treatment being trial and error, well... It is. Your insulin resistance, sensitivity and production are unique to you, just as mine are unique to me. And ever fluctuating too. That's why you need to test a lot as well: to see what is working for you, and what isn't. I can't have pulses, they spike me, save for a tiny little bit of hummus, that i can get away with. Others are fine with pulses, or have a spike just looking at a teaspoon of hummus. Consider yourself your own guinea pig.

Guess this is the point where I ask the next question: what do you eat and drink in a day? https://www.diabetes.co.uk/forum/blog-entry/the-nutritional-thingy.2330/ might give you some idea of potential changes to make... But if you mention every single thing, people here'll be able to suggest alternatives or different brands or.... You know... Help. If we can.

You're going to be okay.
Jo

Stephyr7783 said:

Also my DKA was a euglycemic one, in that my blood sugars were around a normal level when the DKA occurred.

Click to expand...

Hi @Stephyur7783,

Ketoacidosis usually occurs if there is insufficient insulin, so this why @JoKalsbeek was probably asking you about a c-peptide test. Low-carb does work in a somewhat similar way in that in lowers the need for insulin and consequently promotes fat burning. The difference is however in the magnitudes of ketones generated (ketones in ketoacidosis are about 10-fold higher as in nutritional ketosis).

As @bulkbiker has said -- the euglycemia part in your ketoacidosis is due to the SLGT2-inhibitor (dagaflozin) as it spills excess blood sugars into the urine and therefore you don't get the usual "warning sign" of high blood sugars combined with higher ketones, which are typical of ketoacidosis.

I agree also with @JoKalsbeek that it is probably a good idea to at least initially stay above 50g of carbs and to talk to your HCPs about your new way of eating to see if insulin needs to adjusted.

Keeping my fingers crossed that you find a way which works for you.

Stephyr7783 said:

Thank you all so much for your kind replies. The fact that people will make time to reply and advise and offer their own experiences is a great help in itself. Gonna speak to DSN at some point today hopefully, I think they may be getting tired of me but there’s always something else to ask!
I’ve never been offered any information about the status of my body’s own insulin so I’ve honestly no idea whether I still produce or not.

Click to expand...

I had to figure it out on my own. It would've been so much better if I'd found this place sooner. So I'm hoping you'll find here what I so desperately needed back then!

Stephyr7783 said:

Sorry you didn’t have the support you needed, can only imagine how difficult that must have been for you. Hope you’re in a better position now. Have a great weekend.

Click to expand...

Much better, thank you. Blood glucose has been in the normal range for 4 years, lot of other conditions have improved, and if I ever have a question, the hive-mind has answers without judgements. It's good not to have to do this alone.

For a plain ordinary type two, making insulin but having it ignored, then eating fewer carbs lowers blood glucose and empties out the overstuffed storage areas.
It is unusual to have no carbs - I did that for about 2 days after diagnosis as I had been on a high carb diet and wanted to get things flowing the other way. After that I worked up to 50 gm of carbs over a few days and that effectively fixed my diabetes.
I wanted to lower my Hba1c right down, so went to 40, but that had no effect. As my daily levels were normal I just stuck to 40 gm - but I am really sensitive to carbs and I am sure many people can be a bit more relaxed. It is simply a case of eat, test, adjust, until you get to the right place on the carb intake dial.