Today, I am presenting a unique case of a
DKA, which is an acidotic state that can
potentially be deadly.
This case is associated with Jardiance.
It is an SGLT2 inhibitor that is used,
and the case was complicated by ketosis
induced by a ketogenic diet.
And it was unmasking type 1 diabetes in
this patient, previously mistakenly diagnosed and
treated as having type 2 diabetes.
Stay tuned!
The questions we will rise today, guys:
Can ketogenic diet increase the
likelihood of diabetic ketoacidosis in
patients treated with SGLT2 inhibitors,
which are Jardiance, Invokana,
Steglatro and Farxiga. The second question is:
Is ketogenic diet safe in patients with
type 1 or type 1.5 diabetes,
that can be misdiagnosed as type 2
diabetes? Here's our case:
A 70-year-old caucasian woman with a
medical history, significant for type 2
diabetes -It's a diabetes channel- and
hypothyroidism, presented to the
emergency department with
shortness of breath
dizziness
and four days of nausea and vomiting.
On presentation, she had normal vital signs,
except for elevated heart rate.
The remainder of the exam was fairly
unremarkable.
Six months before her presentation,
patient relocated to her current town
and before that time her diabetes was
co-managed by different primary care
doctors. So, she was put on oral agents and
blood sugars were not well controlled, so
she has been transitioned to insulin.
Not uncommonly seen. On initial
evaluation her diabetes was inadequately
controlled by the primary care doctors
and her A1C was around 8.7%
along with, that long-acting glargine
that she was taking at 10 units daily,
and she was also taking
regular correctional insulin, which some
people call sliding scale.
During her follow-up visits, she reported
frequent episodes of early morning hypoglycemia.
Low blood sugars.
Early morning low blood sugars.
She's on insulin, she's having low blood sugars,
now, what do you do? Right? So, you would
think that she's taking probably too
much insulin, but you're right.
So, what they did,
they actually added metformin on top of her regimen
and they discontinued their sliding scale.
Well.
I'm going to come to the bottom of this
case but I'm just going tell you: the
problem here is that they started her on
metformin, which can actually make the
low blood sugar worse,
because she is already on insulin and
long-acting insulin typically cause low
blood sugar if it is given too much.
Although 10 units doesn't sound too much
but for this patient, it was.
It would increase the risk of low blood
sugar. Stopping the sliding scale
wouldn't really change that because
sliding scale insulin typically used for
short-acting insulins and short-acting
insulins will last in your body only
3 to 4 hours. So, overnight, there
will be no effect from the sliding scale
insulin, unless you take the sliding
scale insulin, right before bedtime, which
is not recommended. Anyways, one month
before her admission her A1C actually
increased to 8.9, although she was having
low blood sugars that doesn't make any
sense. So, her blood sugars must be
between 50 and 250 all the time, which we
see frequently at the initial
presentation. So, at that time they said,
okay, we'll add Jardiance to the regiment
because it's just another pill, just
throw another pill, you know. Just because
she's not doing well, just throw another
pill. So, along the same timeline, she also
said; you know what, screw that, I'm just
going to go ahead and start on a ketogenic
diet, because my sugars are running high,
doctors are adding pills and insulin,
nothing is happening, and she was on
protein and fat diet with occasional
salads. So, because of her blood sugar was
not elevated at the presentation, the doctors
were perplexed.
They didn't really think about diabetic
ketoacidosis, because that typically
presents with high blood sugar initially,
not when you're on Jardiance or Farxiga
or Invokana. So, the doctor thought about
potential involvement of Jardiance
because in the label of Jardiance, it
says that it can cause DKA. So, they used
a modified protocol of DKA, because the
protocol of treating a DKA says if your
blood sugar is this high, give this much insulin...
But this patient's sugar was not high
because she was on a ketogenic diet, in
addition to that she was on Jardiance
and insulin but she was still having an
acidotic state, because of a combination
of ketogenic diet and being on Jardiance
at the same time. Then doctors started
thinking about maybe this patient
actually have type 1 diabetes because
for diabetic ketoacidosis to happen
typically patients
need to have minimal to no insulin.
And then they tested GAD
antibodies and GAD antibodies came back
positive, confirming the diagnosis of
type 1 diabetes. Now, in this case you may
say that this is not a clear type 1
diabetes because patient did not present
with DKA initially and did not start on
insulin immediately.
In those cases most of the time we
classify them as actually type 1.5
diabetes, between type 1 and type 2.
But the risk of type 1.5
diabetes is that they have very minimal
insulin production left and agents like
this, like Jardiance or any other SGLT2
inhibitor can throw these people off
into DKA, especially if they are on
ketogenic diet. She was discharged home
on basal-bolus insulin,
so that she doesn't come back with DKA.
And of course Jardiance and Metformin
was discontinued. So, in this patient it
took 36 hours to treat DKA, which is
a stark increase compared to
previously reported cases or typical
cases of 11 hours of DKA resolution. Well,
to conclude guys, this case was a DKA,
diabetic ketoacidosis associated with
Jardiance or any other SGLT2 inhibitor in
that regard and starvation ketoacidosis
resulting from ketogenic diet. So, if
you're on these agents and if you're
trying to be on a keto diet, be extremely
careful and stay away from hospital. Stay
well, stay tuned! We'll see in the next
video, guys!
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