BackgroundVeterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine’s effectiveness in delivering endocrinology care from Atlanta-based endocrinologists.MethodsWe conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth.ResultsThirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans.ConclusionsSpecialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.

Since the approval of sodium-glucose cotransporter 2 (SGLT2) inhibitors by the US Food and Drug Administration for type 2 diabetes, there have been several reports of euglycemic diabetic ketoacidosis in patients using this class of medication. We present a case of euglycemic diabetic ketoacidosis where ketonemia and glucosuria persisted well beyond the expected effect of dapagliflozin. Our patient is a 50-year-old woman with type 2 diabetes since age 35 who was taking metformin and dapagliflozin. She presented with fatigue, constipation, and 3 days of reduced oral intake. Laboratory data indicated anion gap acidosis, ketonemia, severe hypokalemia, and minimally elevated blood glucose. She was treated with sliding scale short-acting insulin and electrolyte replacement until hospital day 6, when endocrinology was consulted. An insulin drip was initiated due to persistent ketonemia and reopening of the anion gap, despite improved oral intake and normoglycemia. On stopping the insulin drip on day 9, the β-hydroxybutyrate increased again. It finally stabilized within normal range with the initiation of basal subcutaneous insulin. This case indicates that clinical effects of dapagliflozin persist much longer than the reported half-life of 12.9 hours would predict. To prevent this potentially dangerous complication, patients taking SGLT2 inhibitors who become ill should discontinue the medication, undergo ketone evaluation, and start basal insulin, if ketones are positive. In addition, patients should be educated to stop their SGLT2 inhibitor at least 1 week prior to elective procedures.

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