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I met Eric a month ago when he was referred to me to start his OmniPod 5 Insulin Pump.
As a diabetes educator and insulin pump trainer, it is my job to contact a patient and ask about their diabetes history and current insulin therapy. When I reached out to him, I learned that he is 41 years old and has had Type 1 Diabetes for about 7 years. Unfortunately, he was never given the opportunity to have diabetes or nutrition education. He was minding his own business when a combination of events resulted in a “perfectly bad storm”. He went to the pharmacy to pick up his Tresiba and NovoLog and found his insurance changed their insulin formulary. He was told that his Tresiba prescription would be $2000.00. He did not pick it up. He continued to take his NovoLog to control his glucose while he tried to work out the insurance problem with his basal insulin. His blood glucose was fairly well controlled between 150-250 while taking only NovoLog.
In the meantime, he continued to eat his low carbohydrate diet and take the SGLT2 inhibitor that his provider prescribed. He started feeling badly with a very sore throat (strep throat in hindsight) and when he started vomiting, he went to the emergency department. When the emergency department ran his initial labs, his blood glucose was 173 but his ketone levels were very high at 4.4 with a normal range of 0-0.6. He was told he had Diabetic Ketoacidosis (DKA) and transferred into the intensive care unit (ICU) and put on an insulin drip and spent the next 4 days and nights in the hospital with the medical team trying to normalize his electrolytes, ketones and blood glucose.
So, what are ketones and how does DKA happen? Ketones are acids made when your body doesn’t have enough insulin to move the glucose from the bloodstream and into the cells. Ketones are produced as a by-product when your body breaks up fat and protein cells to turn them into glucose because the glucose is stuck in the blood stream without enough insulin to move it into the cells for energy. When ketones are produced, they make your blood too acidic (acidosis). Too much acid in your blood might lead to a coma and can be very dangerous.
Infection, illness, and missing insulin injections can cause high glucose and the formation of ketones. Ketones are associated with dehydration from high glucose, vomiting, diarrhea and certain medications that lead to increased urination and fluid loss. Any time a person taking insulin is sick, vomits, or has glucose readings over 300mg/dL, they must check for ketones.
In Eric’s case, he did not know about ketones or have urine ketostix to check them. His blood glucose was below 200 but since he was vomiting and dehydrated, he went to the hospital. He was also taking an SGLT2 inhibitor (Sodium Glucose Co-Transporter 2 inhibitor) which is a medication used to lower blood glucose levels in people with Type 2 diabetes. Some providers may prescribe them “off label” in people with Type 1 diabetes. They work by making the kidneys remove excess sugar through urine adding to the possibility of dehydration. They can be associated with an increased risk of a euglycemic diabetic ketoacidosis (euDKA). Euglycemic means normal glucose so many people may not expect the formation of ketones because the sugar isn’t high. Monitoring ketones regularly is important for Type 1 individuals taking SGLT2 inhibitors especially with illness or dehydration.
So, Eric’s “perfect storm” included an infection – strep throat, a low carb diet (possible starvation ketones) without adequate insulin, an SGLT2 inhibitor, vomiting, dehydration and no prior knowledge of the causes, prevention or treatment of ketones. A $10 bottle of ketostix and diabetes education on taking insulin to clear ketones may have prevented a 4-night stay in the ICU. He now has ketostix as everyone with Type 1 diabetes should. We discussed that ketones could occur quickly in individuals using an insulin pump if the site is dislodged, bent, or clotted with blood interrupting insulin delivery. He is now much more prepared to start his insulin pump. He asked me to share his story so maybe it could prevent the same thing from happening to someone else.
If you should have any questions about ketones and sick day guidelines, reach out to me ( terri@integrateddiabetes.com )or any other provider you work with.
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2 Responses
Very interesting and timely article for me. Thank you
At 64 and a half years old I walked into the hospital DKA with an 830 blood sugar. First indication I had any issue with insulin resistance. Basically my pancreas went on vacation without me and I’m still looking for it. I just left my endocrinologist appointment yesterday afternoon and read this article yesterday evening. She had cautioned me about prolonged fasting without taking any basil insulin, ( I used Toshiba and absolutely love it ) she urged me to take at least a few units a day if I was not going to eat. I will definitely heed that advice on my next three to four day fast. Obviously like anything with diabetes there are a whole lot of mitigating factors in each individuals situation. One that was mentioned in the article is that he’s taking an SGLT inhibitor. I don’t have any idea what that is but I guarantee you I won’t be taking it! I am on insulin only therapy no matter how hard my doctors try to push me to take blood pressure medication, statins, metformin, and all the other crud that is in the standard operational Care manual. I have been dealing with this for now right at 2 years and my A1C as of yesterday was 4.9 and I run anywhere from 89 to 97% in range repeatedly on MDI. My average blood sugar for the close of the week is generally about 115 I’m really striving to get that down to 100 but that’ll take some work. I credit it all to being on an OMAD, extremely low carb diet. I’m beginning to work in exercise but my time schedule is still resistant to it. lmmo.
I wanted to share that I had a very similar experience with DKA. Though no known cause was identified, I ran high blood sugars (160-220) for 3 days and ended up in the ICU. The emergency room nurse looked at my blood sugars and did not realize that it was possible that I was running high ketones when my blood sugars were not that high. I waited for 5 hours and ended up in serious trouble. I share this in part because sometimes we need to learn how to advocate for ourselves even with professionals whose protocol does not allow them to consider our individual differences. I want to share that I am not on a SGLT inhibitor but experienced this same issue.