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BMJ Open Diabetes Research & Care Nov 2023To evaluate awareness and knowledge of diabetic ketoacidosis (DKA), a common and potentially life-threatening complication in people living with type 1 diabetes (T1D).
INTRODUCTION
To evaluate awareness and knowledge of diabetic ketoacidosis (DKA), a common and potentially life-threatening complication in people living with type 1 diabetes (T1D).
RESEARCH DESIGN AND METHODS
A survey was developed to assess individuals' current knowledge, management, and unmet needs regarding DKA. The study was conducted in six Swiss and three German endocrine outpatient clinics specialized in the treatment of diabetes.
RESULTS
A total of 333 participants completed the questionnaire (45.7% female, mean age of 47 years, average duration of T1D at 22 years). Surprisingly, 32% of individuals were not familiar with the term 'diabetic ketoacidosis'. Participants rated their own knowledge of DKA significantly lower than their physicians (p<0.0001). 46% of participants were unable to name a symptom of DKA, and 45% were unaware of its potential causes. 64% of participants did not test for ketones at all. A significant majority (67%) of individuals expressed the need for more information about DKA.
CONCLUSIONS
In patients treated in specialized centers, knowledge of DKA was found to be inadequate, with a lack of understanding regarding symptoms and causes. Healthcare professionals tended to overestimate individuals' knowledge. Future efforts should focus on addressing these knowledge gaps and incorporating protective factors into the treatment of T1D.
Topics: Humans; Female; Middle Aged; Male; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Cross-Sectional Studies; Ketones; Ambulatory Care Facilities
PubMed: 37949471
DOI: 10.1136/bmjdrc-2023-003662 -
Heterogeneity in presentation of hyperglycaemia during COVID-19 pandemic: A proposed classification.Diabetes & Metabolic Syndrome 2021Diabetes and hyperglycemia occurring during COVID-19 era have implications for COVID-19 related morbidity/mortality. In this brief review, we have attempted to... (Review)
Review
Diabetes and hyperglycemia occurring during COVID-19 era have implications for COVID-19 related morbidity/mortality. In this brief review, we have attempted to categorise and classify such heterogenous hyperglycemic states. During COVID-19 pandemic broadly two types of hyperglycemia were seen: one in patients without COVID-19 infection and second in patients with COVID-19 infection. Patients not inflicted with COVID-19 infection and diagnosed with either type 2 diabetes mellitus (T2DM) or type 1 diabetes mellitus (T1DM) show more severe hyperglycemia and more ketoacidosis, respectively. In former, it could be attributed to weight gain, decreased exercise, stress and in both type of diabetes, due to delayed diagnosis during lockdown and pandemic. In patients with COVID-19 and associated pneumonia, altered glucose metabolism leading to hyperglycemia could be due to corticosteroids, cytokine storm, damage to pancreatic beta cells, or combination of these factors. Some of these patients present with diabetic ketoacidosis, hyperglycemic hyperosmolar state or both. We have provided a framework for categorisation of hyperglycemic states, which could be consolidated/revised in future based on new research data.
Topics: Blood Glucose; COVID-19; Diabetic Ketoacidosis; Humans; Hyperglycemia; Pandemics
PubMed: 33588198
DOI: 10.1016/j.dsx.2021.01.018 -
The Journal of Clinical Endocrinology... Aug 2020Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as an important class of blood glucose-lowering medications, due to cardiovascular, metabolic, and renal... (Review)
Review
INTRODUCTION
Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as an important class of blood glucose-lowering medications, due to cardiovascular, metabolic, and renal benefits. However, there is a small but significant risk of diabetic ketoacidosis (DKA) associated with their use.
METHODS
A literature search was conducted in Ovid MEDLINE and Embase to July 2019 using variants on the key search terms sodium-glucose cotransporter 2, diabetic ketoacidosis, and type 2 diabetes. A broad spectrum of evidence was incorporated to facilitate a comprehensive narrative review. Further sources were identified through hand searching of reference lists.
DISCUSSION
Although cardiovascular outcome trials demonstrated mixed evidence of SGLT2i associated DKA, increasing evidence from case reports and cohort studies has identified an increased risk. SGLT2i use is associated with a ketotic state caused by an increased glucagon:insulin ratio and stimulated by factors including stress-induced hormonal changes, insufficient insulin, decreased glucose, increased ketone resorption, and hypovolemia. Atypical presentations of DKA with lower-than-expected blood glucose levels are possible with SGLT2i use, so clinical and biochemical monitoring is vital for early identification and management. DKA risk is particularly increased with precipitating factors, therefore optimization of risk factors is vital. Recommendations for perioperative and sick day management of patients taking SGLT2i have been suggested based on available evidence.
CONCLUSION
SGLT2i are an excellent class of drug in the physician's toolkit for managing type 2 diabetes. However, both clinicians and patients must be aware of the potential for DKA and the need for increased monitoring, both clinically and biochemically, when potential precipitating factors are present. In acutely unwell patients, these medications should be withheld to reduce the risk of DKA.
Topics: Blood Glucose; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Patient Selection; Risk Factors; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 32302001
DOI: 10.1210/clinem/dgaa200 -
Diabetes & Metabolic Syndrome Dec 2023Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies....
BACKGROUND AND AIMS
Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies. The present study aimed to compare the spectrum and outcomes of diabetic ketoacidosis (DKA) between elderly and non-elderly adult patients in India.
METHODS
Seventy-seven elderly patients (≥60 years) were compared to 477 non-elderly patients (13-59 years) with DKA admitted to the medical emergency, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2014 and December 2022. Clinical features, laboratory parameters, precipitating factors, and in-hospital outcomes were reviewed.
RESULTS
Elderly patients less commonly had vomiting and abdominal pain than non-elderly patients (31.3 % vs. 66.2 %, 27.3 % vs. 60.1 %, respectively) and typically presented with dyspnea (48.5 %), altered mental status (47.8 %), and fever (46.3 %). Ketonemia and metabolic acidosis were significantly more marked in non-elderly patients, whereas elderly patients frequently had anemia, hypoalbuminemia, and renal dysfunction. The most common precipitations of geriatric DKA were infections (70.1 %), followed by treatment non-adherence (66.2 %) and non-infectious disorders (35.1 %). Infections and non-infectious disorders were significantly more frequent in elderly patients than in non-elderly patients. Respiratory and urinary tract infections were prevalent in both age groups. In-hospital survival was 74.9 % (n = 415) and remained lower in older patients (48.1 % vs. 79.2 %, P-value <0.001). The independent prognostic factors were age (OR 1.030, 95 % CI 1.006-1.054, P = 0.014), Glasgow coma scale (OR 0.789, 95 % CI 0.717-0.869, P <0.001), and infection trigger (OR 6.635, 95 % CI 2.852-15.441, P <0.001).
CONCLUSION
Older patients with DKA present atypically, frequently have precipitation with infections and noninfectious disorders, and have poor outcomes.
Topics: Adult; Aged; Humans; Middle Aged; Diabetic Ketoacidosis; Hospitals; Hospitalization; Abdominal Pain; Precipitating Factors; Retrospective Studies; Diabetes Mellitus
PubMed: 37988830
DOI: 10.1016/j.dsx.2023.102903 -
Diabetes/metabolism Research and Reviews Mar 2022The COVID-19 pandemic might have a multifaceted effect on children with type 1 diabetes (T1D), either directly through infection itself or indirectly due to measures...
Higher rates of diabetic ketoacidosis and admission to the paediatric intensive care unit among newly diagnosed children with type 1 diabetes in Kuwait during the COVID-19 pandemic.
INTRODUCTION
The COVID-19 pandemic might have a multifaceted effect on children with type 1 diabetes (T1D), either directly through infection itself or indirectly due to measures implemented by health authorities to control the pandemic.
OBJECTIVE
To compare data on children newly diagnosed with T1D in Kuwait during the COVID-19 pandemic to the pre-pandemic period.
RESEARCH DESIGN AND METHODS
We analysed data on children aged 12 years or less registered in the Childhood-Onset Diabetes electronic Registry (CODeR) in Kuwait. Data were incidence rate (IR), diabetic ketoacidosis (DKA), and its severity and admission to the paediatric intensive care unit (PICU).
RESULTS
The IR of T1D was 40.2 per 100,000 (95% CI; 36.0-44.8) during the COVID-19 pandemic period and was not statistically different from pre-pandemic. A higher proportion of incident T1D cases presented with DKA and were admitted to the PICU during the pandemic (52.2% vs. 37.8%: p ˂ 0.001, 19.8% vs. 10.9%; p = 0.002, respectively). The COVID-19 pandemic was positively associated with presentation of DKA and admission to PICU (AOR = 1.73; 95% CI, 1.13-2.65; p = 0.012, AOR = 2.04; 95% CI, 1.13-3.67; p = 0.018, respectively). Children of families with a positive history for diabetes were less likely to present with DKA and get admitted to the PICU during the COVID-19 pandemic (AOR = 0.38; 95% CI, 0.20-0.74; p = 0.004, AOR = 0.22; 95% CI, 0.08-0.61; p = 0.004, respectively).
CONCLUSION
High rates of DKA at presentation and admission to PICU in incident T1D cases during the COVID-19 pandemic warrant further studies and effective mitigation efforts through increasing awareness, early detection, and timely intervention.
Topics: COVID-19; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Humans; Intensive Care Units, Pediatric; Kuwait; Pandemics; SARS-CoV-2
PubMed: 34679258
DOI: 10.1002/dmrr.3506 -
Pediatric Emergency Care May 2015Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency... (Review)
Review
Diabetic ketoacidosis is a common problem among known and newly diagnosed diabetic children and adolescents for which they will often seek care in the emergency department (ED). Technological advances are leading to changes in outpatient management of diabetes. The ED physician needs to be aware of the new technologies in the care of diabetic children and comfortable managing patients using continuous subcutaneous insulin infusions. This article reviews the ED management of diabetic ketoacidosis and its associated complications, as well as the specific recommendations in caring for patients using the continuous subcutaneous insulin infusion, serum ketone monitoring, and continuous glucose monitoring.
Topics: Adolescent; Child; Diabetic Ketoacidosis; Disease Management; Emergency Medicine; Emergency Service, Hospital; Humans
PubMed: 25931345
DOI: 10.1097/PEC.0000000000000429 -
Diabetes & Metabolic Syndrome 2019Although diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic...
AIMS
Although diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA.
MATERIALS AND METHODS
A retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BE) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L.
RESULTS
The initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BE (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA.
CONCLUSIONS
Correction of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis.
Topics: Adult; Alkalosis; Chlorides; Diabetic Ketoacidosis; Female; Follow-Up Studies; Humans; Hyperglycemia; Hypoglycemic Agents; Insulin; Male; Middle Aged; Prognosis
PubMed: 30641700
DOI: 10.1016/j.dsx.2018.08.015 -
Current Diabetes Reports Jul 2017Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents. They are increasingly being prescribed in the outpatient diabetic... (Review)
Review
PURPOSE OF REVIEW
Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents. They are increasingly being prescribed in the outpatient diabetic population. In this review, we examine the risks and benefits of continuation and initiation of SGLT2 inhibitors in the inpatient setting.
RECENT FINDINGS
There are currently no published data regarding safety and efficacy of SGLT2 inhibitor use in the hospital. Outpatient data suggests that SGLT2 inhibitors have low hypoglycemic risk. They also decrease systolic blood pressure and can prevent cardiovascular death. The EMPA-REG study also showed a decrease in admissions for acute decompensated heart failure. There have been increasing cases of diabetic ketoacidosis, and specifically the euglycemic manifestation, associated with SGLT2 inhibitors use. We present two cases of inpatient SGLT2 inhibitor use, one of continuation of outpatient therapy and one of new initiation of therapy. We then discuss potential risks and methods to mitigate these as well as benefits of these medications in the inpatient setting. We cautiously suggest the use of SGLT2 inhibitors in the hospital. However, these must be used judiciously and the practitioner must be aware of euglycemic diabetic ketoacidosis and its risk factors in this population.
Topics: Aged; Diabetic Ketoacidosis; Hospitalization; Hospitals; Humans; Male; Risk Factors; Sodium-Glucose Transporter 2; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 28597228
DOI: 10.1007/s11892-017-0874-3 -
Tropical Doctor Jul 2022Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19)...
Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19) pandemic. We conducted a prospective cohort study to evaluate the spectrum and outcomes of adult DKA during the pandemic and document differences in DKA patients with or without COVID-19. A total of 169 patients (mean age 44 years) were admitted at the Emergency Department of PGIMER, Chandigarh (India), from January 2020 to June 2021. The precipitating factors were noncompliance with antidiabetic therapy (77.5%), infections (62.7%), and noninfectious conditions (21.3%). Thirty-nine (23.1%) patients had COVID-19, including 31 with severe infection. DKA severity and resolution, ventilator requirement, hospital stay, and mortality were similar in the patients with or without COVID-19. In-hospital mortality was 39.6% (n = 67). The independent mortality predictors were ventilator requirement (-0.000), an infection trigger (-0.049), and hyperosmolarity (-0.048). DKA mortality is increased significantly during the pandemic.
Topics: Adult; COVID-19; Diabetes Mellitus; Diabetic Ketoacidosis; Humans; India; Pandemics; Prospective Studies
PubMed: 35300552
DOI: 10.1177/00494755221076896 -
Journal of General Internal Medicine Apr 2023Starvation ketosis and pancreatitis are uncommon and underrecognized etiologies of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is associated commonly with...
Starvation ketosis and pancreatitis are uncommon and underrecognized etiologies of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is associated commonly with pregnancy, use of insulin en route to the hospital, and use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. A 58-year-old male with past medical history of type II diabetes mellitus and alcoholism presented with chief complaint of nausea, vomiting, and poor oral intake for several weeks. Despite extensive history of diabetes and no recent SGLT-2 inhibitor use, his labs were consistent with euglycemic DKA. His imaging and clinical history also confirmed alcoholic pancreatitis. The patient was admitted for euglycemic DKA secondary to starvation ketosis and alcoholic pancreatitis. His anion gap and beta-hydroxybutyrate rapidly cleared with initiation of the DKA protocol. This case teaches us that clinicians should consider early initiation of the DKA protocol even in the setting of euglycemia, when a patient presents with high-anion-gap metabolic acidosis, a high beta-hydroxybutyrate level, and a clinical picture of pancreatitis and starvation.
Topics: Male; Female; Pregnancy; Humans; Middle Aged; Diabetic Ketoacidosis; Diabetes Mellitus, Type 2; Pancreatitis, Alcoholic; 3-Hydroxybutyric Acid; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 36689144
DOI: 10.1007/s11606-022-07993-5