Diabetic Ketoacidosis After Bariatric Surgery in Type 2 Diabetes

Diabetic ketoacidosis (DKA) is a potentially life threatening complication that can occur in people with diabetes.  While we typically associate DKA with type 1 diabetes, it can also rarely happen in type 2 diabetes.   DKA can occur if insulin levels are low, and can be precipitated by a stress on the body, including infection or illness, dehydration, heart attack, and so forth.

A case series was recently published, describing four cases of DKA after bariatric surgery, in three people with type 2 diabetes.   The average time to presentation of DKA was 13 days after surgery (range 3-27 days). All patients were on insulin prior to surgery.  Factors contributing to DKA included omission of insulin and dehydration.

One of these patients was on canagliflozin prior to surgery.  Canagliflozin is a medication in a class of type 2 diabetes medications called SGLT-2 inhibitors, which slightly increase the risk of DKA, particularly if insulin is not taken as directed by the health care team.  Also, if a person taking an SGLT2 inhibitor becomes unwell or dehydrated for any reason while taking the medication, this increases the risk of DKA.  The DKA case in the patient on canagliflozin in this study also had omission of insulin and poor food intake post operatively as contributory factors.

These findings teach us the following:

1.  Patients with type 2 diabetes having bariatric surgery need to be followed closely postoperatively, with meticulous attention to blood sugars and insulin needs.  Some people with type 2 diabetes who were on insulin before surgery do not require insulin after surgery, but others do.   There must also be a low threshold for concern if they become dehydrated due to difficulty tolerating oral intake.

2.  SGLT2 inhibitors should be stopped prior to bariatric surgery (possibly before starting any low calorie diet plan), and if there is still a need for medication to control blood sugar post op, it should not be restarted until the patient is eating and drinking well after discharge home from surgery.

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www.drsue.ca © 2016

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JDRF Reaches Out To Fort McMurray Evacuees with Type 1 Diabetes

In the wake of the wildfires that have ravaged Fort McMurray, there have been many heartwarming stories of outreach and support to victims of this monumental natural disaster.

The JDRF (formerly known as the Juvenile Diabetes Research Foundation) is reaching out to Fort Mac victims living with type 1 diabetes to help ensure they have ongoing access to insulin, test strips and supplies.  Here is the media release directly from the JDRF:

Media Advisory

JDRF Canada Assisting Fort McMurray Individuals Living with Type 1 Diabetes

The North Central Alberta & Northwest Territories Chapter of JDRF Canada is coordinating with local type 1 diabetes (T1D) support groups to provide assistance for T1D families evacuated from Fort McMurray with their insulin related needs.

Families who were forced to evacuate may have limited access to insulin, test strips and other related supplies. Local social media groups for people living with T1D have been very active with families offering to share their supplies with families in need. “Many people are now in the Edmonton Area while others are in camps around Fort McMurray”, said Dorothy Ross, Regional Director for JDRF in Western Canada “We are compiling the lists of people that are in need with people who can share some of their supply, both in the Fort McMurray area and in other communities in the region.”

People who are either in need of or able to offer supplies can contact JDRF at1-855-428-0343 or local at 780-428-0343. For after hours support, please e-mail Edmonton@jdrf.ca. JDRF staff will coordinate resources with those in need.

About JDRF

JDRF is the leading global organization funding type 1 diabetes (T1D) research. JDRF’s goal is to progressively remove the impact of T1D from people’s lives until we achieve a world without T1D. JDRF collaborates with a wide spectrum of partners and is the only organization with the scientific resources, regulatory influence, and a working plan to better treat, prevent, and eventually cure T1D. As the largest charitable supporter of T1D research, JDRF is currently sponsoring $530 million in scientific research in 17 countries. For more information, please visit JDRF.ca.

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Type 2 Diabetes Medication Semaglutide Reduces Cardiac Risk

Great news from the diabetes world: semaglutide, a medication in development for the treatment of type 2 diabetes and obesity, has been shown to reduce the risk of cardiovascular events.

The SUSTAIN-6 study (a study in which I was an investigator) was a global study of about 3,300 people with type 2 diabetes, who were randomized to receive semaglutide subcutaneously (injected under the skin) once weekly vs placebo for treatment of their diabetes. They found that after 2 years of treatment, semaglutide reduced cardiovascular events (defined as a sum of non fatal heart attack, non fatal stroke, and cardiovascular death).  Exactly how much the risk is reduced is not yet public knowledge - the information is currently available in a press release only, with the exact data to be released at a later date.

Semaglutide is a GLP-1 receptor agonist, which helps the pancreas control the release of hormones involved in blood sugar control (insulin and glucagon), and also stimulates the fullness centre in the brain to tell a person that they feel full.  Thus, not only does it help with blood sugar control, it is also effective for weight loss.  Semaglutide is currently in development as both a type 2 diabetes treatment and as a treatment for obesity in people with or without diabetes (it is not yet available as a prescription).   Interestingly, while all GLP-1 receptor agonists currently available are administered by injection under the skin (similar to how insulin is administered), semaglutide is also currently under development as an oral medication. (ie as a pill)

This marks the third time in the last eight months that we have been so thrilled to hear that a medication designed for the treat type 2 diabetes decreases the risk of cardiovascular events: empagliflozin (trade name Jardiance) (read here) and liraglutide (trade name Victoza) (read here) reduce cardiovascular events as well.  These are landmark times for the world of type 2 diabetes, as prior to these studies, we had not definitively proven that a medication for treatment of type 2 diabetes could decrease the risk of cardiovascular events.  In fact, we have had great difficulty proving that improving blood sugar control by any means reduces cardiovascular events (though it is clear that improving blood sugar control reduces the eye and kidney complications of diabetes).

Amongst the class of GLP-1 receptor agonists, both liraglutide and semaglutide have shown that they reduce cardiovascular events (though the numbers on this are not yet available on either one), whereas lixisenatide (not available in Canada) did not decrease cardiovascular events.  It remains to be seen what effect the other GLP-1 receptor agonists available in Canada have on cardiovascular events (exenatide (trade names Bydureon and Byetta) and dulaglutide (trade name Trulicity)) - these studies are still underway.


Disclaimer: I am involved in research trials of semaglutide for type 2 diabetes and obesity.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk). 

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www.drsue.ca © 2016

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