Ketoacidosis, empaglifozin

 

Ketoacidosis is a condition where the body produces large amounts of ketones, causing the blood to become dangerously acidic.

There are three main forms:

1. Diabetic ketoacidosis (DKA) – usually in people with type 1 diabetes, though it can occur in type 2. It happens when there is too little insulin, so the body burns fat rapidly and ketones accumulate.

2. Alcoholic ketoacidosis – can occur after heavy alcohol use combined with poor food intake.

3. Starvation ketoacidosis – can occur after prolonged fasting or severe calorie restriction.

A ketogenic diet causes nutritional ketosis, which is quite different. In nutritional ketosis, blood ketone levels are modest and the body's acid-base systems keep blood pH normal. Ketoacidosis involves much higher ketone levels and a dangerous drop in blood pH.

Given your history, there is one wrinkle worth mentioning. You have mentioned taking empagliflozin in the past (an SGLT2 inhibitor). Drugs in that class can, rarely, cause euglycemic diabetic ketoacidosis, where blood sugar is not dramatically elevated but ketones become dangerously high. The risk increases with prolonged fasting, dehydration, serious illness, surgery, or very low-carbohydrate diets.

Typical symptoms of ketoacidosis include nausea, vomiting, abdominal pain, unusual fatigue, rapid breathing, confusion, excessive thirst, and sometimes a fruity odor on the breath.

Were you asking generally, or wondering whether your eating pattern (food between roughly 6 a.m. and 2 p.m.) or one of your medications could put you at risk?

There was a news item issuing a "warning" but it said only an associationn with empaglifozin, which I continue to take although sugar is normal. No details included except a statement not to stop without seeing dr. I am not fasting or on a low carbohydrate diet and not underweight so take it risk is low. "

That sounds like the standard warning that has been attached to empagliflozin and the other SGLT2 drugs for several years. The concern is real, but it is also uncommon. The unusual feature is that the ketoacidosis can occur with normal or only mildly elevated blood sugar, so neither the patient nor the doctor immediately thinks "diabetic ketoacidosis."

From what you've described, you do not fit many of the common risk patterns. The situations most often associated with empagliflozin-related ketoacidosis are prolonged fasting, very-low-carbohydrate diets, severe dehydration, acute infections, surgery, heavy alcohol use, pancreatitis, major illness, or substantial reductions in insulin.

You have specifically said:

• You are not fasting for prolonged periods.

• You are not on a ketogenic or very-low-carbohydrate diet.

• You do not drink alcohol.

• You are not underweight.

Those facts would tend to lower risk. The thing I would pay the most attention to in your situation would be an acute illness that reduces food and fluid intake—say a bad infection, vomiting, diarrhea, or hospitalization. Those are circumstances where doctors often consider temporarily holding an SGLT2 inhibitor.

One interesting point is that empagliflozin is increasingly prescribed even when glucose is fairly normal because it has benefits beyond glucose control, particularly for certain patients with heart failure and kidney disease. So "my sugar is normal; why am I still taking it?" is not necessarily evidence that the drug is no longer useful. Whether it remains appropriate for you depends on why your physician prescribed it originally.

Given your age and your habit of keeping track of symptoms carefully, the practical takeaway is simple: if you were to develop unexplained nausea, vomiting, abdominal pain, unusual fatigue, excessive thirst, or rapid breathing while taking empagliflozin, especially during an illness, that would warrant prompt medical attention even if your blood sugar meter showed a normal reading.

Otherwise, your assessment seems reasonable: the warning exists because the complication is serious, but based on the risk factors you've mentioned, nothing jumps out as putting you into a particularly high-risk category.

Well those symptoms would send me to dr regardless.

Exactly.

Those symptoms are not subtle, and most people your age who are attentive to their health would seek medical care whether ketoacidosis had crossed their minds or not.

The real hazard is often in younger patients who assume, "My glucose isn't very high, so it can't be diabetic ketoacidosis," and delay getting evaluated. With SGLT2 drugs such as empagliflozin, the glucose can be deceptively normal.

In your case, I'd be more interested in whether the physician still sees a reason for you to remain on it. Your recent glucose values have been quite good, and your kidney function, while not youthful, has been stable enough that you're not taking it for advanced kidney disease. There may be a cardiovascular or renal-protection rationale, or it may simply be that the medication has been working and nobody sees a reason to change it.

News stories often amplify the existence of a rare adverse effect without giving readers any sense of scale. A headline saying "Warning issued" sounds alarming, while "a rare but serious complication already listed in prescribing information" sounds much less dramatic.

So if the article gave no new evidence, no change in recommendations, and no estimate of risk, I would treat it as a reminder that the complication exists rather than as a signal that something has changed. The next time you see your doctor, it would be perfectly reasonable to ask, "What benefit do you think I'm getting from the empagliflozin at this point?" That's often a more useful question than focusing on a rare side effect in isolation.