Diabetes in Urban African-Americans. I. Cessation of Insulin Therapy Is the Major Precipitating Cause of Diabetic Ketoacidosis

Musey, Victoria C.; Lee, Jenny K; Crawford, Rochanda; Klatka, Morel Ann; McAdams, Debra; Phillips, Lawrence S.

doi:10.2337/diacare.18.4.483

Cited by 113 publications

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“…Although it has been repeatedly shown that infection is a common precipitating event in DKA and HHS in this country and abroad (4,12), recent studies suggest that omission of insulin or undertreatment with insulin may be the most important precipitating factor in urban African-American populations (5,26). Table 3 summarizes various studies (2,5,6,(27)(28)(29)(30) describing precipitating events for DKA.…”

Section: Precipitating Events -mentioning

confidence: 99%

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Management of Hyperglycemic Crises in Patients With Diabetes

et al. 2001

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Abbreviations: AaO 2 , alveolar-to-arteriolar oxygen; AKA, alcoholic ketoacidosis; ARDS, adult respiratory distress syndrome; BUN, blood urea nitrogen; CPT, carnitine palmitoyl-transferase; CSF, cerebrospinal fluid; DKA, diabetic ketoacidosis; FFA, free fatty acid; HHS, hyperosmolar hyperglycemic state; IRI, immunoreactive insulin; PaO 2 , arteriolar partial pressure of oxygen; RDKA, recurrent DKA.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Management of Hyperglycemic Crises in Patients With Diabetes T E C H N I C A L R E V I E R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s 132DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001Technical Review noted in newly diagnosed obese type 2 diabetic patients (5,26,31). Therefore, the concept that the presence of DKA in type 2 diabetes is a rare occurrence is incorrect.The most common types of infections are pneumonia and urinary tract infection, accounting for 30-50% of cases (Table 4). Other acute medical illnesses as precipitating causes include alcohol abuse, trauma, pulmonary embolism, and myocardial infarction, which can occur both in type 1 and 2 diabetes (6). Various drugs that alter carbohydrate metabolism, such as corticosteroids, pentamidine, sympathomimetic agents, and ␣-and ␤-adrenergic blockers, and excessive use of diuretics in the elderly may also precipitate the development of DKA and HHS.The recent increased use of continuous subcutaneous insulin infusion pumps that use small amounts of short-acting insulin has been associated with an incidence of DKA that is significantly increased over the incidence seen with conventional methods of multiple daily insulin injections, in spite of the fact that most of the mechanical problems with insulin pumps have been resolved (6,(32)(33)(34). In the Diabetes Control and Complications Trial, the incidence of DKA in patients on insulin pumps was about twofold higher than that in the multipleinjection group over a comparable time period (35). This may be due to the exclusive use of short-acting insulin in the pump, which if interrupted leaves no reservoir of insulin for blood glucose control.Psychological factors and poor compliance, leading to omission of insulin therapy, are important precipitating factors for recurrent ketoacidosis. In young female patients with type 1 diabetes, psychological problems complicated by eating disorders may be contributing factors in up to 20% of cases of recurrent ketoacidosis (36,37). Factors that may lead to insulin omission in younger patients include fear of weight gain with good metabolic control, fear of hypoglycemia, rebellion against authority, and stress related to chronic disease (36). Noncompliance with insulin therapy has been found to be the leading precipitating cause for DKA in urban African-Americans and medically indigent patients (5,26). In addition, a recent study showed that diabetic patients without health insurance or with Medicaid alone had hospitali...

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Section: Precipitating Events -mentioning

confidence: 99%

“…Technical Review noted in newly diagnosed obese type 2 diabetic patients (5,26,31). Therefore, the concept that the presence of DKA in type 2 diabetes is a rare occurrence is incorrect.…”

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confidence: 99%

Management of Hyperglycemic Crises in Patients With Diabetes

et al. 2001

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“…Slovis et al [9] reported that an elevated band neutrophil count could reliably predict the existence of serious occult bacterial infections in adults with DKA. However, the majority of adult studies have failed to show a clear association between the presence of leukocytosis and the existence of infections in the patient population [6,7].…”

Section: Introductionmentioning

confidence: 99%

“…Defined by the triad hyperglycemia, acidosis, and ketonuria, DKA can be inaugural or complicate diabetes [2]. Although DKA is the evidence of poor metabolic control and usually indicates an absolute or relative imbalance between the patient's requirements and the treatment, DKA-related mortality is low among patients who received standardized treatment, which includes administration of insulin, correction of hydroelectrolytic disorders, and management of the triggering factor (which is often cessation of insulin therapy, an infection, or a myocardial infarction) [3][4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

Prediction and rate of infections in diabetes mellitus patients with diabetes ketoacidosis in Penang, Malaysia

Gillani¹,

Sulaiman²,

Sundram³

2012

OJEpi

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Study aimed to determine the rate and prediction of infection in diabetes mellitus patients ≥ 18 year, with diabetic ketoacidosis (DKA). Retrospective cohort study design was adopted to achieve the objectives. Universal sampling technique was employed for data collection among Diabetes ketoacidosis patients, over a period of 3 years (Jan 2008-Dec 2010). Statistical package for social sciences used to analyze data. Over a 3-year period, total of 967 admissions were identified. Of it, 112 (11.6%) with no infection, 679 (70.2%) with bacterial infection and 176 (18.2%) with presumed viral infection. The mean WBC for all the patients was 18,177 (±9431). 721 (74.6%) had leukocytosis, as defined by a WBC ≥ 15,000/mm 3 . WBC, differential, leukocytosis, as well as sex, temperature were not significant predictors (p > 0.05) of bacterial infection. There was significant (p < 0.05) difference of age between the 3 groups, age above 57 years have high rate of infection as compared to age below and equal 57 years. The infection rate in elderly patients with DKA was high and majority of them had lack of clinical evidence. Major bacterial infections with potential serious sequel were particularly common (33.3%), among every third patient being presumed to have serious consequences.

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“…Patient-related factors such as income, age, years of education, occupation, and literacy (10 -12), as well as failure to keep appointments (13), poor adherence to prescribed hypoglycemic medications (14), and lack of understanding of diabetes and the importance of good glycemic control (15), can limit the effectiveness of management. However, provider-related factors may be even more important, since providers often fail to intensify diabetes therapy appropriately when patient glycemic control is poor (16,17).…”

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Rapid A1c Availability Improves Clinical Decision-Making in an Urban Primary Care Clinic

et al. 2003

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OBJECTIVE -Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit. Frequency of intensification of pharmacological diabetes therapy in inadequately controlled patients and A1c levels were assessed at baseline and after follow-up.RESULTS -We recruited 597 subjects. Patients were 79% female and 96% African American, with average age of 61 years, duration of diabetes 10 years, BMI 33 kg/m 2 , and A1c 8.5%. The rapid and routine groups had similar clinical demographics. Rapid A1c availability resulted in more frequent intensification of therapy when A1c was Ն7.0% at the baseline visit (51 vs. 32% of patients, P ϭ 0.01), particularly when A1c was Ͼ8.0% and/or random glucose was in the 8.4 -14.4 mmol/l range (151-250 mg/dl). In 275 patients with two follow-up visits, A1c fell significantly in the rapid group (from 8.4 to 8.1%, P ϭ 0.04) but not in the routine group (from 8.1 to 8.0%, P ϭ 0.31).CONCLUSIONS -Availability of rapid A1c measurements increased the frequency of intensification of therapy and lowered A1c levels in patients with type 2 diabetes in an urban neighborhood health center. Diabetes Care 26:1158 -1163, 2003A lthough diabetes is a common disease that can lead to significant morbidity and mortality (1,2), there is strong evidence that achieving good glycemic control can delay or prevent complications of both type 1 and type 2 diabetes (3-6). However, many patients continue to have high levels of glucose and A1c (7-9) and remain at risk for end-organ damage.The reasons for failure to achieve the American Diabetes Association (ADA) goals for glycemic control are not well understood. Patient-related factors such as income, age, years of education, occupation, and literacy (10 -12), as well as failure to keep appointments (13), poor adherence to prescribed hypoglycemic medications (14), and lack of understanding of diabetes and the importance of good glycemic control (15), can limit the effectiveness of management. However, provider-related factors may be even more important, since providers often fail to intensify diabetes therapy appropriately when patient glycemic control is poor (16,17). Such "clinical inertia" (18,19) slows the process of achieving therapeutic targets and could compromise the ability of health care systems to reduce the morbidity, mortality, and costs associated with diabetes. Moreover, interventions aimed at overcoming clinical inertia can improve glycemic control in a municipal hospital setting, where many patients are affected by poverty and limited literacy (18).Clinical inertia might be due in part t...

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Diabetes in Urban African-Americans. I. Cessation of Insulin Therapy Is the Major Precipitating Cause of Diabetic Ketoacidosis

Cited by 113 publications

References 0 publications

Management of Hyperglycemic Crises in Patients With Diabetes

Management of Hyperglycemic Crises in Patients With Diabetes

Prediction and rate of infections in diabetes mellitus patients with diabetes ketoacidosis in Penang, Malaysia

Rapid A1c Availability Improves Clinical Decision-Making in an Urban Primary Care Clinic

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