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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 -
Pediatric Diabetes Sep 2022Before 2016, no child was known to survive type 1 diabetes (T1D) in Laos, a lower-middle income country (LMIC) in South-east Asia. In partnership with the Laos...
OBJECTIVE
Before 2016, no child was known to survive type 1 diabetes (T1D) in Laos, a lower-middle income country (LMIC) in South-east Asia. In partnership with the Laos government, a non-government organization (NGO) called Action4Diabetes (A4D) has since been providing insulin, blood glucose monitoring kits, HbA1c testing, and emergency hospital expenses for Laotian children and young people (CYP) with T1D, and education for healthcare professionals. Here, we report the demographics and clinical outcomes of the CYP with T1D enrolled in A4D's Clinic Support Programme.
RESEARCH DESIGN AND METHODS
We collated and analyzed data on all known CYP with T1D in Laos, including gender, age and presentation at diagnosis, duration of diabetes, hospital admissions, and glycemic control during follow-up.
RESULTS
Fifty-three CYP (30 male; 57%) were diagnosed with T1D at a mean age of 11.3 years. Thirty CYP (57%) presented in diabetic ketoacidosis (DKA) at diagnosis. As at 16 August 2021, mean duration of T1D was 2.3 years. Forty-five CYP (85%) remained on active follow-up. Mean HbA1c for all 53 CYP was 8.7% (72 mmol/mol). Average HbA1c for the CYP in the age ranges of 1-5 years, 6-10 years, 11-15 years, 16-20 years, and 21-25 years, was 7.9% (63 mmol/mol), 8.2% (66), 8.4% (68), 9.4% (79), and 8.4% (68), respectively.
CONCLUSIONS
This is the first report on the status of T1D care in Laos, achieved through close partnership between the government and an NGO from 2016 to 2021. More global efforts to improve T1D care outcomes in Laos and other LMICs are urgently needed.
Topics: Adolescent; Adult; Blood Glucose; Blood Glucose Self-Monitoring; Child; Child, Preschool; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Glycated Hemoglobin; Humans; Infant; Laos; Male; Young Adult
PubMed: 35598163
DOI: 10.1111/pedi.13366 -
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 -
Diabetes/metabolism Research and Reviews Sep 2021Diabetic ketoacidosis (DKA) is an acute metabolic complication characterized by hyperglycaemia, ketones in blood or urine, and acidosis.
BACKGROUND
Diabetic ketoacidosis (DKA) is an acute metabolic complication characterized by hyperglycaemia, ketones in blood or urine, and acidosis.
OBJECTIVE
The aim of this study was to characterize features of patients hospitalized for DKA, to identify triggers for DKA and to evaluate the long-term effects of DKA on glycaemic control, complications of diabetes, re-hospitalizations, and mortality.
METHODS
Historical prospectively collected data of patients hospitalized to medical wards for DKA between 2011 and 2017. Data regarding comorbidities, mortality, triggers, and re-hospitalizations for DKA were also collected.
RESULTS
The cohort consisted of 160 patients (mean age 38 ± 18 years, 43% male). One fifth of the patients (34 patients, 21%) were newly diagnosed with diabetes, and DKA was their first presentation of the disease. Among the 126 patients with pre-existing diabetes, the common identified triggers for DKA were poor compliance to treatment (22%) and infectious diseases (18%). During over 7 years of follow-up, mortality rate was 9% (15 patients), and re-hospitalization for DKA rate was 31% (50 patients). Risk factors for re-hospitalization for DKA included young age (OR = 1.02, 95% CI, 1.00-1.04), pre-existing diabetes compared to DKA as the first presentation (OR = 5.4, 95% CI, 1.7-18), and poorer glycaemic control before initial hospitalization (10.5 ± 2.5% vs. 9.4 ± 2.2%; OR = 0.8, 95% CI [0.68-0.96]) and after discharge (10.3 ± 2.4% vs. 9.0 ± 1.9%; OR = 0.73, 95% CI [0.61-0.87]). Laboratory tests during the initial hospitalization, smoking, alcohol, or comorbidities did not increase the risk for re-hospitalization for DKA.
CONCLUSIONS
The risk for readmission for DKA is higher for young patients with long duration of diabetes, poor compliance of insulin treatment and poorly controlled diabetes.
Topics: Adult; Cohort Studies; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Hospitalization; Humans; Hyperglycemia; Male; Middle Aged; Retrospective Studies; Risk Factors; Young Adult
PubMed: 32942337
DOI: 10.1002/dmrr.3408 -
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 -
The American Journal of the Medical... May 2021
Topics: Adult; COVID-19; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Male; Middle Aged; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 34024356
DOI: 10.1016/j.amjms.2020.11.027 -
Pediatric Nephrology (Berlin, Germany) Apr 2024The last decade has been characterized by exciting findings on eu- or hypoglycemic ketosis and ketoacidosis. This review emphasizes the following five key points: 1.... (Review)
Review
The last decade has been characterized by exciting findings on eu- or hypoglycemic ketosis and ketoacidosis. This review emphasizes the following five key points: 1. Since the traditional nitroprusside-glycine dipstick test for urinary ketones is often falsely negative, the blood determination of β-hydroxybutyrate, the predominant ketone body, is currently advised for a comprehensive assessment of ketone body status; 2. Fasting and infections predispose to relevant ketosis and ketoacidosis especially in newborns, infants, children 7 years or less of age, and pregnant, parturient, or lactating women; 3. Several forms of carbohydrate restriction (typically less than 20% of the daily caloric intake) are employed to induce ketosis. These ketogenic diets have achieved great interest as antiepileptic treatment, in the management of excessive body weight, diabetes mellitus, and in sport training; 4. Intermittent fasting is more and more popular because it might benefit against cardiovascular diseases, cancers, neurologic disorders, and aging; 5. Gliflozins, a new group of oral antidiabetics inhibiting the renal sodium-glucose transporter 2, are an emerging cause of eu- or hypoglycemic ketosis and ketoacidosis. In conclusion, the role of ketone bodies is increasingly recognized in several clinical conditions. In the context of acid-base balance evaluation, it is advisable to routinely integrate both the assessment of lactic acid and β-hydroxybutyrate.
Topics: Infant, Newborn; Child; Female; Humans; Hypoglycemic Agents; Diabetic Ketoacidosis; 3-Hydroxybutyric Acid; Lactation; Ketosis; Ketone Bodies
PubMed: 37584686
DOI: 10.1007/s00467-023-06115-5 -
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 -
Diabetes & Metabolic Syndrome 2021To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies.
AIMS
To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies.
METHODS
Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2).
RESULTS
385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018).
CONCLUSION
High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.
Topics: Adult; Aged; Biomarkers; Blood Glucose; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Female; Follow-Up Studies; Glycated Hemoglobin; Hospitalization; Humans; Israel; Male; Middle Aged; Prognosis; Recurrence; Retrospective Studies; Risk Factors
PubMed: 34509792
DOI: 10.1016/j.dsx.2021.102276