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Diabetes Research and Clinical Practice Sep 2019Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation... (Review)
Review
AIMS
Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition.
METHODS
Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines.
RESULTS
The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult.
CONCLUSIONS
DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
Topics: Adult; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Prevalence; United Kingdom
PubMed: 31344382
DOI: 10.1016/j.diabres.2019.107797 -
Current Diabetes Reports May 2017Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the... (Review)
Review
PURPOSE OF REVIEW
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries.
RECENT FINDINGS
Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.
Topics: Diabetic Ketoacidosis; Humans; Hyperglycemic Hyperosmolar Nonketotic Coma; United Kingdom; United States
PubMed: 28364357
DOI: 10.1007/s11892-017-0857-4 -
BMJ (Clinical Research Ed.) Nov 2020
Review
Topics: Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Hypoglycemic Agents; Risk Factors; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 33184044
DOI: 10.1136/bmj.m4147 -
Pediatrics in Review Aug 2019
Review
Topics: Child; Diabetic Ketoacidosis; Humans; United States
PubMed: 31371634
DOI: 10.1542/pir.2018-0231 -
The Veterinary Clinics of North... May 2023Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications... (Review)
Review
Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.
Topics: Animals; Cats; Dogs; Hyperglycemic Hyperosmolar Nonketotic Coma; Pets; Cat Diseases; Dog Diseases; Diabetic Ketoacidosis; Diabetes Mellitus
PubMed: 36898859
DOI: 10.1016/j.cvsm.2023.01.005 -
BMJ Open Diabetes Research & Care Oct 2023Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor... (Review)
Review
Euglycemic diabetic ketoacidosis (EDKA) is an emerging complication of diabetes associated with an increasing use of sodium-glucose transporter type 2 (SGLT-2) inhibitor drugs. This review highlights the growing incidence of EDKA and its diagnostic challenges due to the absence of hallmark hyperglycemia seen in diabetic ketoacidosis (DKA). The paper presents a classification system for the severity of EDKA, categorizing it into mild, moderate, and severe based on serum pH and bicarbonate levels. Another classification system is proposed to define stages of EDKA based on anion gap and ketones at the time of diagnosis and during the treatment period. A treatment algorithm is proposed to guide clinicians in managing EDKA. This treatment algorithm includes monitoring anion gap and ketones to guide insulin and fluid management, and slower transition to subcutaneous insulin to prevent a relapse. Increased awareness of EDKA is essential for a timely diagnosis because an early diagnosis and treatment can improve clinical outcomes.
Topics: Humans; Diabetic Ketoacidosis; Sodium-Glucose Transporter 2 Inhibitors; Diabetes Mellitus, Type 2; Insulin; Ketones
PubMed: 37797963
DOI: 10.1136/bmjdrc-2023-003666 -
Paediatric Drugs Aug 2020Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with... (Review)
Review
Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.
Topics: Adolescent; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Fluid Therapy; Humans; Insulin
PubMed: 32449138
DOI: 10.1007/s40272-020-00397-0 -
Metabolism: Clinical and Experimental Apr 2016The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic... (Review)
Review
The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.
Topics: Animals; Diabetes Mellitus; Diabetic Ketoacidosis; Humans; Incidence
PubMed: 26975543
DOI: 10.1016/j.metabol.2015.12.007 -
Clinical Therapeutics Dec 2016Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the... (Review)
Review
PURPOSE
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA.
METHODS
Reports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel.
FINDINGS
DKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended.
IMPLICATIONS
Preventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.
Topics: Blood Glucose; Canada; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Hypoglycemic Agents; Incidence; Insulin; Sodium-Glucose Transporter 2; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 28003053
DOI: 10.1016/j.clinthera.2016.11.002 -
Postgraduate Medical Journal Oct 2021The genesis of ketone bodies by organisms is a protective mechanism. This metabolic process helps organisms to survive acute metabolic derangements in times of nutrient... (Review)
Review
The genesis of ketone bodies by organisms is a protective mechanism. This metabolic process helps organisms to survive acute metabolic derangements in times of nutrient deficiency. When prolonged, ketogenesis leads to ketoacidosis, which is a potentially life-threatening metabolic disorder due to the accumulation of keto-acids in the body. The most common cause is diabetic ketoacidosis, though starvation ketoacidosis and alcoholic ketoacidosis are not uncommon. The presentation of all ketoacidotic states is similar-being generally unwell, abdominal pain, rapid and shallow breathing, vomiting and dehydration. Non-diabetic ketoacidotic states are very commonly overlooked due to relative unawareness among the clinicians, leading to misdiagnosis and thereby inappropriate management culminating in added mortality and morbidity. We describe here six cases of alcoholic and starvation ketoacidosis, review the literature currently available and discuss the common pitfalls in managing such cases.
Topics: Abdominal Pain; Adolescent; Adult; Aged; Diabetic Ketoacidosis; Female; Humans; Keto Acids; Ketosis; Male; Middle Aged
PubMed: 33246966
DOI: 10.1136/postgradmedj-2020-138513