digest
Short Summary
Main recommendation: Patients taking SGLT2 inhibitors such as Jardiance, Invokana, Steglatro, or Farxiga should be extremely careful about following a ketogenic diet, because the combination can trigger diabetic ketoacidosis (DKA). The video presents a case of a 70-year-old woman, previously treated for type 2 diabetes, whose DKA was ultimately linked to type 1.5 diabetes, unmasked by the drug and diet.
Key Points
- DKA is described as an acidotic state that can be deadly; in this case it was linked to Jardiance (an SGLT2 inhibitor) plus a ketogenic diet of mostly protein and fat with occasional salads.
- The patient's blood sugar was not elevated at presentation, which initially confused doctors because DKA usually presents with high blood sugar.
- The Jardiance label warns that the drug can cause DKA, which prompted doctors to reconsider the drug's role.
- Positive GAD antibodies confirmed type 1 diabetes, and Dr. Ergin classifies this case as type 1.5 because the patient did not present with DKA initially and was not started on insulin immediately.
- Type 1.5 patients have very little remaining insulin production, making them more vulnerable to SGLT2 inhibitor-induced DKA, especially on a ketogenic diet.
Details Worth Noting
- Concrete instructions: Dr. Ergin's advice: patients on SGLT2 inhibitors who are considering a ketogenic diet should be extremely careful, so as to avoid ending up in the hospital. The video also notes that a patient with suspected type 1 or type 1.5 diabetes who is misdiagnosed as type 2 may face this risk, so those diagnoses should be considered when DKA appears with normal glucose.
- The patient's A1C was about 8.7% initially and rose to 8.9% a month before admission, while she was on glargine at 10 units daily plus correctional insulin.
- She had frequent early-morning hypoglycemia, and the video argues that metformin added on top of insulin can worsen low blood sugar, while stopping sliding-scale insulin would not change overnight effects because short-acting insulin lasts only three to four hours.
- Treatment took 36 hours to resolve DKA in this patient, compared with about 11 hours in previously reported or typical cases, as noted by Dr. Ergin.
- At discharge she was placed on basal-bolus insulin, and Jardiance and metformin were discontinued.
Bottom Line: The case shows that an SGLT2 inhibitor combined with a ketogenic diet can cause DKA even with normal blood sugar, and that unrecognized type 1 or type 1.5 diabetes may be behind it. The video reports these findings without presenting them as professional medical advice.
