By: Ivette L., LW Dietetic Intern

         When it comes to people with diabetes, folks assume all are type 2 and it is associated with old age and/or excess weight. While this observation is not wrong, it is quite far from the entire picture. There is actually more than one type of diabetes, but in order to understand them, let’s begin with what diabetes actually is. Diabetes is defined as, “a disease where the body cannot make or doesn’t make enough insulin (a pancreatic hormone) resulting in high blood sugar in the bloodstream.” Type 2 diabetes, the most recognized form, is a condition where the body isn’t producing enough insulin or is insulin resistant causing high blood sugar (hyperglycemia). It normally occurs in adults but can affect children. It is also preventable. Similar to type 2, there is gestational diabetes which only develops during pregnancy. Pregnant women are usually tested between 24-28 weeks. Gestational diabetes should go away after giving birth but increases odds of developing type 2 diabetes in the future. (CDC 2020)

Type 1 diabetes, which is less common and therefore often misunderstood, is an autoimmune disease during which your body does not produce ANY insulin. It is formerly known as juvenile diabetes but can be diagnosed at any age. Unfortunately, there is no research on prevention. Currently, the only approved medical treatment for type 1 diabetes is insulin therapy consisting of a combination of short or fast acting and intermediate, or long-acting that is administered via a syringe, pen, or through an insulin pump. Newer insulins include Afrezza which is an inhalable fast acting insulin. The only permitted alternate medication is the oldest type 2 medication, metformin, or Symlin (injectable anti-diabetic medication that acts like a hormone to lower blood sugar) combined with insulin. (Janssens, Caerels & Mathieu 2020)

Everyone thinks they can tell type 1 from type 2 if the person is overweight. The heavier ones are people with type 2 diabetes, and the type 1’s are leaner. However, recent research is demonstrating that this isn’t always the case. Over 50% of people with type 1 diabetes are now in the obese category. Excess body weight is linked to inconsistent blood sugar levels, overcorrection of low blood sugar episodes, unhealthy diet, and lack of physical activity. It can lead to increased risk of insulin resistance, cardiovascular disease, chronic kidney disease, and other diabetes related complications. In recent years, a term known as “off label use” has been applied to diabetes care. This occurs when medications used and approved to treat one thing are prescribed to treat another condition. In this case, the off label drugs are the type 2 diabetes medications that are being used to treat type 1 diabetes. The latest drugs being used are: SGLT-2 inhibitors (sodium-glucose cotransporter-2 Inhibitors). Some known examples are Invokana, Jardiance, and Farxiga. In Europe, this is a widely used practice as it has been officially approved there. Unfortunately for Americans, the FDA has not authorized  the use of SGLT-2 inhibitors for type 1 diabetes. (Hage et al 2019)

How do SLGT-2 inhibitors help people with type 1 diabetes anyway? The medication, in pill form, blocks the SGLT-2’s (transport proteins in the kidneys) ability to trap sugar, or glucose, in the bloodstream and is instead filtered out of the kidneys leaving the body in our urine. This then lowers A1C levels, requires less insulin, increases insulin sensitivity, and decreases chances of cardiovascular disease. Another useful bonus is that it produces weight loss. The idea is that by losing all that sugar that comes from the food we eat, we are cutting down our calorie intake. (Janssens, Caerels & Mathieu 2020)

This all sounds so incredible and easy so why aren’t endocrinologists running to call all of their patients with type 1 diabetes who may be overweight and insulin resistant? For one, there simply isn’t enough research for doctors to determine if it’s safe enough to prescribe. Secondly, despite the wonderful benefits discussed here, there are concerning side effects. The biggest concern is that usually when a person with type 1 diabetes also takes a type 2 medication like Invokana or Farxiga, they are more likely to get DKA which for any person with diabetes that you ask is their absolute worst nightmare. 

Diabetic ketoacidosis , DKA, develops when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Your energy deprived body tries to get fuel from the liver. When the liver breaks down the fat in order to make energy, it produces an acid in your blood. When this goes on for a prolonged time, the acidic buildup in your blood becomes a very risky situation. Think of insulin as the key needed to unlock your blood cells to let the sugar in. You can force open with another key but this can only work for so long. (Meena 2020)

SLGT-2  inhibitors tend to cause euglycemic DKA which is like a sneaky and deceptive type of DKA. It is DKA but with blood sugar numbers under 250. Euglycemic DKA is more dangerous because it can be hard to detect if you’re only testing your blood sugars. This is why it is so important to watch out for other telltale signs such as vomiting, lethargy, large amounts of ketones in the urine, and extreme thirst. Euglycemic DKA is rare and typically only happens to people with type 1 diabetes using SLGT-2 inhibitors.(Meena 2020) Because the medication is causing you to release excess sugar through your urine, it tricks your body into thinking it needs less insulin, when our bodies require insulin 24/7 in order to stabilize our blood sugars. So you can have what you think are “decent” blood sugars and your body still needs more insulin! Other possible side effects include frequent urinary tract infections due to excessive urination and hypoglycemic (low blood sugar) episodes. (Geerlings et al 2014)

Now to the question of the hour, is it worth the risk? Depends. As a person with diabetes for over 20 years who also happens to be insulin resistant and obese, my endocrinologist has suggested SLGT-2 inhibitors several times. While it’s an unconventional treatment, my doctor is confident it will help bring down my blood sugars, reduce my overall insulin requirements, and help me lose some weight. I’ve resisted because of the intense fear of euglycemic DKA. Luckily, I’ve never experienced ketoacidosis, but from what other fellow T1Ds have said, it’s horrible. Because of my hectic lifestyle with grad school, work, and my dietetic internship, I preferred to wait until I had more time to closely monitor myself for any signs of euglycemic DKA. Now that I am done with grad school, I will begin using Invokana with my insulin pump. Am I scared? Yes, but after having done the research and trying the traditional method of increasing physical activity, I am willing to cautiously forge ahead. That being said, I wouldn’t recommend it to all  people with type 1 diabetes. If you are able to lose weight the old-fashioned way and are NOT significantly insulin resistant, I would caution against it and stick to what we know works for us. It requires additional planning and discipline. If you are someone who may not be able to handle the added stress of having yet another diabetes red flag to watch out for, then maybe reconsider. After all, we cannot forget that these medications were not intended to treat type 1 diabetes.

References 

Geerlings, S., Fonseca, V., Castro-Diaz, D., List, J., & Parikh, S. (2014). Genital and urinary tract infections in diabetes: Impact of pharmacologically-induced glucosuria. Diabetes Research and Clinical Practice, 103(3), 373-381. doi:10.1016/j.diabres.2013.12.052

Hage, L. E., Kashyap, S. R., & Rao, P. (2019). Use of SGLT-2 Inhibitors in Patients With Type 1 Diabetes Mellitus. Journal of Primary Care & Community Health, 10, 215013271989518. doi:10.1177/2150132719895188

Janssens, B., Caerels, S., & Mathieu, C. (2020). SGLT inhibitors in type 1 diabetes: Weighing efficacy and side effects. Therapeutic Advances in Endocrinology and Metabolism, 11, 204201882093854. doi:10.1177/2042018820938545

Meena, P., MD. (2020, September 14). SGLT2 Inhibitor-induced Euglycemic Diabetic Ketoacidosis. Retrieved October 9, 2020, from https://www.renalfellow.org/2020/09/08/sglt2-inhibitor-induced-euglycemic-diabetic-ketoacidosis/

What is diabetes? (2020, June 11). Retrieved October 8, 2020, from  https://www.cdc.gov/diabetes/basics/diabetes.html