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SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

Discussion in 'Other Diabetic Medications' started by Oldvatr, Jul 9, 2016.

  1. Bluetit1802

    Bluetit1802 Type 2 (in remission!) · Legend

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    OMG

    I am so glad I am med free. I wouldn't take that group of drugs under any circumstances.
     
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  2. ickihun

    ickihun Type 2 · Master

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    I don't mind being the alarmist on this occasion. Its so damaging to diabetics who rely on their mobility to maintain their diabetes. Mobility is a huge part of maintenance.
    I feel like a fish with one fin :(
     
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  3. Indy51

    Indy51 Type 2 · Expert

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  4. ickihun

    ickihun Type 2 · Master

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    I guess the trials on the drugs didn't include those eating habits!
     
  5. lazza1973

    lazza1973 · Newbie

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    Helpful!!!?????
     
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  6. ringi

    ringi Type 2 · Well-Known Member

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    We have two separate issues
    • a possible increased risk of ketoacidosis
    • the clear risk that A&E sends someone with ketoacidosis home
    Personally I think SGLT2 inhibitors are too great a risk unless it has been proved that someone is producing a reasonable amount of their own insulin, hence is of low risk of ketoacidosis. Maybe (SGLT2) inhibitors should only be used if someone's self produced insulin levels are above normal. (Classic Type2 with clear insulin resistance is after all what the drug maker targeted them at.)

    I would like to see everyone taking SGLT2 inhibitors be given a card and medical bracelet stating that BG level must not be used to rule out ketoacidosis, along with a ketones meter that is good enough to clearly show the difference between normal levels of ketones for someone not eating carbs and ketoacidosis. (Drip sicks may not be good enough to clearly show the difference.)

    We have seen many people with clear cases of Type1 (but believed to have Type2) being send home just because their BG is "only" in the 20s due to them eating low carb, clearly (SGLT2) inhibitors can greatly increase this risk.

    Remember that it is someone who may have been on duty for 12hrs, dealing with lots of people who have just gone into A&E for no good reasons, and without having any experience of diabetes decides if you should be seen now or in 4 hours time, or just send home.

    I have not seen anything that makes me believe that SGLT2 inhibitors increases the risk of ketoacidosis regardless of carb intake, but they clearly increase the risk of the ketoacidosis being ignored until it is too late. But SGLT2 inhibitors ate still new so not well understood.
     
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  7. ringi

    ringi Type 2 · Well-Known Member

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    Can one of the mods add the names of the SGLT2 inhibitors used in the UK to the title of this thread - doing so may safe someone's life by making this thread show up better on google.
     
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  8. Oldvatr

    Oldvatr Type 2 · Expert

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  9. Liam1955

    Liam1955 Type 2 · Master

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  10. Indy51

    Indy51 Type 2 · Expert

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    @ringi - my warning was based on a video talk I saw where the risk of dehydration with both fasting and low carb diets was mentioned as a contraindication for those taking SGLT2 inhibitors. I only wish I could remember who the speaker was!

    Dehydration is one of the reasons most low carb experts recommend additional salt and increased water to avoid keto "flu". I think it's also a concern with fasting.
     
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  11. Oldvatr

    Oldvatr Type 2 · Expert

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    We can live longer without food but cannot live for long without water. I remember the hunger strilers in Irelamd in the Maze prison. They refused food, but not water.
     
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  12. ringi

    ringi Type 2 · Well-Known Member

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    dehydration clearly needs to be controlled for regardless of how someone is eating if they are taking SGLT2 inhibitors. Shame there is not a simple test for dehydration (that I know of) that is valid for someone with diabetes.
     
  13. Indy51

    Indy51 Type 2 · Expert

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    Since the action of SGLT2 inhibitors promote urination, they already have an inherent risk for dehydration. Adding further risks on top of the inherent risk is probably not a good idea.
     
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  14. ringi

    ringi Type 2 · Well-Known Member

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    The problem is that once low carb and intermittent fasting has failed there are no good option for anyone with insulin resistance, it then comes down to a balance of risks, including long term risks of stokes and hart issues from an above normal insulin level.
     
  15. Oldvatr

    Oldvatr Type 2 · Expert

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    Firstly you appear to accept the hypothesis that IR can only be 'cured' by LC+IF. The science has not yet proven this and the jury is still out in this. Secondly SGLT-2 Inhibitors are being prescribed for Insulin Dependants as well as T2D, so high insulin is controllable in their case. What you describe is the status quo that is the lot for most diabetics suffering this progressive disease (???) and yes, we could default back to this if LC+IF does not work. What does this have to do with SGLT-2 Inhibitors? If they work well then the sugar goes down the drain [literally], and we will be ok. My OP was to show that this particular path seems to carry a certain amount of risk that users need to be made aware of, as well as HCP's.

    Keeping well hydrated may be the key to keeping the DKA monster in check, and is good advice for people taking these meds. I hope it is as simple as that, and then all we will contend with is UTI and possible AKI as a follow on. There are a few others such as pancreitis and bladder cancer, with the occasional broken bone to wake us up to the apparent fact that these meds are not as safe as NICE and the manufacturers would have us believe. Why can't we incorporate FDA warnings into the UK care system? Why are drugs that are prescribed daily in the UK banned or severely restricted in US? I am thinking of Actos, and thalidomide for starters.
     
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  16. ringi

    ringi Type 2 · Well-Known Member

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    I take Metformin as a "given" for IR and assume that everyone who can will take it. I would love science to come up with other options for IR, but none seem to be in the pipeline.

    Remember that for a long time the USA banned Metformin partly due to a claimed increase risk of DKA! FDA warnings are often based on a single case and should be considered by UK consultants, but may be too much information to expect UK GP to consider, however FKA warning are made use of by NICE.

    Whenever a doctor tells me that everyone should take Satins, I remind them about Thalidomide and the dangers of mass medications of the population. These days Thalidomide is used on a very limited bases including for some cancers and I expect that GPs are not allowed to prescribe it, but it is life saving for a few people.
     
  17. Oldvatr

    Oldvatr Type 2 · Expert

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    https://medlineplus.gov/druginfo/meds/a696005.html
    Reading between the lines, it would seem there may be a connection between dehydration and DKA, but it seems to be the elephant in the room. We see it with SGLT-2 Inhibitors, and here with Metformin, but no one is giving a definitive answer on what is triggering the serious condition, We are still in the dark as to a cause.

    I was on Actos until my second stroke, and was only taken off it when it becsme contraindicted for patients who Already had a CVE, but not newbies, even though the med is associated with causing said CVE in the first place. It is banned in USA and I believe on the Continent and India since 2011 , but not in UK. I firmly believe statins will turn out to be a similar bad choice, and they (Big Pharma) are pushing them for an increasing number of conditions so that eventually the whole world will be on them. Does the name Damien mean anything to you> The Omen? or Stoma in Brave New World?

    Having discovered the very dubious trial data that the drug companies used to justify statins in the first place, then I will never use them again. Their statistics has been demonstrated to be open to misinterpretation and the false determination of cause . effect, and is open to misuse. Did they misuse this? From the two reports I studied, there was no way I could get the raw data to substantiate their conclusions, and it seem I am not alone in making this observation. The textbook describing the statistics methods has been withdrawn from publication, on the grounds I outline above, The few library copies that remain are overstamped Archive info only, Not to be used for new investigations. The online version has a Front sheet making this same declaration. New studies aince2016 must use different methodology, ans should be more believable, but reportds from before this date must be considered suspect, expecially since it is usually the companies themselves doing the research, and funding it and writing the conclusions too, Vested interest. Moi?
     
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  18. Indy51

    Indy51 Type 2 · Expert

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    Adding a postscript to this thread. During his talk at Low Carb Breckenridge 2018, Dr Eric Westman advised very strongly that people taking SGLT-2 inhibitors should NOT attempt a ketogenic diet:

    [​IMG]
     
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  19. Oldvatr

    Oldvatr Type 2 · Expert

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    His warning is specific for keto type diets, but the referenced case study just specifies a low carb diet. I would suggest that both are relevant to this warning. I believe that ketoacidosis has also been reported with other diets too, and I am not sure that ketosis elevates the risk to any greater degree. It is the action of these meds that is at fault since they interfere with the kidney filtration and excretion pathway. which in turn leads to a buildup of waste products,
     
  20. ickihun

    ickihun Type 2 · Master

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    Thank you for this @Indy51.
    Very very wise advice and should be taken seriously.
    I know because canagliflozin didn't work out well for me. In any way, shape or form. I'm quite anti canagliflozin as only after taking thus drug did I start deteriating physically. I still cannot walk without pain.
    That is not me, I've always been very very physically able!
    My body changed after canagliflozin tablets! Be warned!!!
     
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