O O O….Oh no! By: Sasha Klemawesch, MD

O O O….Oh no! By: Sasha Klemawesch, MD

If you are a non-streaming luddite like me who still watches cable, then I’m sure you could not only sing the Ozempic jingle on command, but probably do the Jardiance-Lady’s dance as well. There’s been so much hype around the novel diabetic agents, I thought it worth discussing some of their downsides, since otherwise mainly what you hear are social media-ites & bravo-lebrities lauding them as quick & easy weight loss hacks.

While it’s true (especially for the Ozempics/Mounjaro’s of the bunch), that they do help you lose weight, it’s also true that along w that desired benefit comes the potential for many adverse effects. 

Let’s look at Jardiance – aka – Empagliflozin first. This is an SGLT-2 Inhibitor, which is a different class from the others. It essentially makes your kidneys pee out boatloads of glucose, which in turn causes you to pee out high volumes of urine. The medical term for this is “osmotic diuresis.” If you remember from high school science, when you have two containers of water connected by a semi-permeable-membrane, one side w salt water, the other w tap, the tap water will selectively flow through to the side with the salt, in attempts to balance the ratio of salt: water on both sides. The kidneys do the same thing when you have excessive sugar in the urine; they send excessive water/fluid after it; which is why Jardiance not only lowers Blood Sugar, but also (partially) why it has a proven benefit in Heart Failure patients. (a key component of treating heart failure is keeping body fluid low, keeping patients ‘dry’). However, Glucosuria (glucose in urine) is also the reason for the main adverse effects I see time & time again in the ED; the 3 main ones being UTIs, Dehydration/Acute kidney failure, and Euglycemic Ketoacidosis.

UTI is simple enough. Bacteria love sugar, they need it to live and thrive. When you have too much sugar coursing through your genitourinary tract, bacteria show up to party, increasing the likelihood of infections throughout it.

Dehydration and Kidney Failure. Sounds scary, but Dehydration IS (in medical terms at least) the mild form of         “Pre-Renal Acute Kidney Failure.” It simply means that you’re so dehydrated that your creatinine level (aka “kidney number”) goes up a little when you run lab work. Treatment is very simple. IV fluids (or oral), and your labs go back to normal and everything is fine. Occasionally though, the degree of renal dysfunction can get severe enough to necessitate admission to the hospital for ongoing fluid resuscitation and lab monitoring.

Euglycemic Ketoacidosis. This is the most severe of the adverse sequalae that I have personally seen come through the ED. Most people have heard of DKA, Diabetic Ketoacidosis. This is similar in that it involves the pH level of your body becoming dangerously low, and requires treatment in the ICU w an insulin infusion. The difference here is that your glucose level is normal, and because of that, many times this condition can be overlooked and underrecognized, especially if you happen to be seen by a provider who is not aware of what it is or how it presents. Unfortunately, that is not uncommon, and it doesn’t help that its symptoms are quite vague; nausea, stomach upset, fatigue, weakness, etc. 

Now to the other family of meds which includes Ozempic, Victoza, Wegovy, Saxenda, Rybelsus, and Mounjaro. All but Mounjaro are GLP-1 Agonists. Mounjaro is both a GLP-1 and GIP Agonist. GLP-1 Agonism exerts several effects. It slows gastric emptying, so food stays in your stomach longer, you feel fuller longer and therefore naturally start eating smaller portions.  It also increases insulin production, decreases glucagon release (a hormone that raises blood sugar), and has direct effects in brain centers involved in both physiologic appetite and psychologic food cravings. It also affects acid secretion in the stomach (which can cause some nausea/ queasiness), and that, combined w the effects in the brain and the slowed gastric emptying all combine to severely curb appetite and food consumption. The GIP in Mounjaro does all the same things since GIP and GLP-1 are closely related hormones, but the addition of it leads to synergism such that all the effects are compounded and weight loss is augmented.

The most common complaint I see in these medicines is the nausea and stomach upset. The worst effect I have seen (and I have personally had 4 patients so far with it) is pancreatitis. Pancreatitis can range from painful but not dangerous to potentially life-threatening. Two of my 4 patients went to the ICU, one went to Med-Surg, and one went home.

Another increasingly common issue coming to light w these meds is that they are forcing surgeons and anesthesiologists to adjust their OR scheduling. While “nothing after midnight” has been the pre-op mantra for decades, nowadays 6 hours NPO is becoming woefully inadequate; patients are regurgitating and sometimes aspirating when they start to get put under, since food is staying in their stomachs for so much longer. They are having to either come off their meds briefly or try and not eat for prohibitively long times before the OR.

But probably the biggest drawback of these medicines is their cost and availability, since they are all quite expensive, and right now the demand is still eclipsing supply.

What is the bottom line of all this? All of these meds are wonderful additions to the diabetes and obesity medicine arsenals, but they are by no means miracle cures. If you are taking one or considering one, just be aware of and be prepared for possible side effects. You can help to avoid many of the common adverse effects of Jardiance by keeping up your fluid intake. Unfortunately, there is not much you can do to avoid being the unlucky one who gets pancreatitis.

But DO feel reassured that my POV is skewed, since I only see bad outcomes in the ED. There are millions of other people out there doing great on them….   And if you need proof, just turn on your TV!

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