Understanding the Risks of SGLT2 Inhibitors and Euglycemic DKA
My spouse, a 68-year-old male with well-managed type 2 diabetes (typically maintaining an A1C of 7.3 for the last two years), has no other medical conditions. He has been taking Metformin at a dosage of 1000 mg twice daily, along with Jardiance at 25 mg, Ozempic at 0.5 mg, and Glipizide 10 mg two times a day. In early February, he contracted the flu. Three days into his illness, he experienced a worrying change in his mental state, showing confusion and difficulty recalling his recent meals, along with bouts of weakness and shortness of breath, accompanied by greenish-gray phlegm. The following morning, we went to the emergency room, where he was subsequently admitted for observation. Testing revealed he had Influenza A and a decreased oxygen level while walking. He also suffered an acute kidney issue (with a GFR of 45), and lab results indicated high glucose levels at 290, a creatinine level of 1.57 mg/dl, BUN at 28 mg/dl, and a urinary ketone result at 20, with glucose in the urine exceeding 1000. Due to his elevated blood sugar levels, sliding scale insulin was administered. He was discharged with a Medrol pack (steroids) and Tamiflu, and he was instructed to continue with his oral medications. Notably, he did not receive a diabetes consultation, and a telehealth appointment with a physician lasted only 18 minutes, after which a nursing practitioner facilitated his discharge. Just three days later, during a visit with his primary care physician, no lab work was conducted, medications were not reviewed, and risk factors associated with post-viral complications were not discussed; she simply scheduled a follow-up in six months. Four days post-visit, we returned to the ER, where the physician suspected Euglycemic DKA, linking it to the Jardiance treatment. This was subsequently confirmed by an endocrinologist, who noted concerns about the medication's impact. He was hospitalized that evening in a standard room but was initially placed on a non-DKA insulin drip protocol. By 8 PM, they initiated the DKA treatment protocol. Unfortunately, by 1 AM, he fell while attempting to get out of bed; his blood sugar plummeted to the low 40s, and he was only able to recognize his identity amidst confusion, with his oxygen saturation dropping to the low 80s. Critical care was called, and after about 40 minutes of attention at his bedside, he was moved to the ICU. I was contacted but was merely informed that it was a minor fall, accompanied by a negative CT scan, and that he was experiencing difficulty breathing, hence the ICU transfer. I'm seeking clarity on how these events unfolded. This was an alarming experience, and I aim to avoid a recurrence of such circumstances. A new endocrinology practitioner disregarded the concerns surrounding Jardiance. How should I proceed from here?
Answers (1)
3/24/2025, 1:10:56 AM
OpenHealth AI
I'm sorry to hear about your spouse's challenging experience. It's understandable to feel alarmed and confused given the complexity of his condition. Let's break down the situation and outline steps to manage his diabetes and prevent future complications effectively.
Key Points
- Euglycemic DKA and SGLT2 Inhibitors: Jardiance, an SGLT2 inhibitor, can lead to euglycemic diabetic ketoacidosis (DKA), particularly during periods of stress like illness. Managing his diabetes actively, especially after illnesses, is crucial.
- Monitoring and Medication Review: Due to the recent hospitalization and complications, a thorough review and adjustment of his diabetes management plan are necessary.
- Immediate Steps: Focus on consistent blood glucose monitoring, recognizing symptoms of DKA, and maintaining communication with healthcare providers.
Explanation
Euglycemic DKA can occur even when blood glucose levels are not excessively high, particularly when an SGLT2 inhibitor like Jardiance is involved. The flu likely caused increased stress on his body, elevating the risk of DKA even further. His confusion and difficulty recalling meals may be related to fluctuating blood sugar levels, which can be dangerous.
Additionally, the acute kidney issue (with decreased GFR) also implies that his body is under stress and possibly affecting how his medications are processed.
Next Steps
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Daily Monitoring:
- Check blood glucose levels regularly, ideally several times a day, and maintain a log. Look for patterns in blood sugar levels during and after illness.
- Monitor for symptoms of DKA, such as excessive thirst, frequent urination, nausea, abdominal pain, or confusion. Contact medical help if any occur.
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Medication Review:
- Request an urgent follow-up with an endocrinologist or a diabetes specialist to review all medications. Discuss the ongoing use of Jardiance, especially given the recent DKA episode. Consider potential alternatives if the risks are deemed too high.
- Discuss adjusting doses of Metformin, Ozempic, and Glipizide based on his recent hospitalization, kidney function, and blood sugar history.
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Communication with Healthcare Providers:
- Maintain open lines of communication with his healthcare team. Given the complexities of his case, ensure they are all aware of his previous hospitalizations and the specific concerns about euglycemic DKA.
- Advocate for more frequent consultations and lab work to assess his kidney function and overall diabetes management.
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Education and Support:
- Consider diabetes education programs that can provide additional support on managing diabetes, understanding medications, and recognizing signs of complications.
- Look into resources such as local support groups for individuals living with diabetes to gain insights and share experiences.
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Emergency Action Plan:
- Create an emergency plan for future incidents. This plan should include specific symptoms to monitor, when to contact healthcare providers, and emergency contact information.
Conclusion
Your spouse's experience is understandably concerning, and taking proactive steps is essential to avoid recurrence. Focus on monitoring his condition closely, reviewing medications with a specialist, and ensuring effective communication with his healthcare providers. Don't hesitate to reach out for additional support or guidance as needed.
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