 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 Jordyans. 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. So the questions we will rise today guys. Can ketogenic diet increase the likelihood of diabetic ketosis in patients treated with SGLT2 inhibitors which are Jordyans in Vokana, Steglato and Farsiga? The second question is, is ketogenic diet safe in patients with type 1 or type 1 and a half 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 duh 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 so the remainder of the exam was fairly unremarkable. So six months before her presentation patient relocated to her current down 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 glardine that she was taking at ten 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. So low blood sugars, early morning low blood sugars. So 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 gonna come to the bottom of this case but I'm just gonna 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 ten 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 insulin and short-acting insulin will last in your body only three to four 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 sugar 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 Jardins to the regimen 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 gonna 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 Jardins or Farsiga or in Volcano. So the doctor thought about potential involvement of Jardins because in the label of Jardins 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 Jardins and insulin but she was still having an acedotic state because of a combination of ketogenic diet and being on Jardins 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 and a half diabetes is that they have very minimal insulin production left and agents like this like Jardins or any other SGLT2 inhibitor can throw this 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 Jardins 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 the Jardins 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. Hey guys I hope you're enjoying this channel so far and I hope you subscribed already. If you didn't do it and if you did watch this video right there I think that will help you too.