Effect of COVID-19 on the clinical course of diabetic ketoacidosis (DKA) in people with type 1 and type 2 diabetes

Kempegowda, Punith; Melson, Eka; Johnson, Agnes; Wallett, Lucy; Thomas, Lucretia; Zhou, Dengyi; Holmes, Catherine; Juszczak, Agata; Karamat, Mohammed Ali; Ghosh, Sandip; Hanif, Wasim; Narendran, Parth; Bellary, Srikanth

doi:10.1530/ec-20-0567

Cited by 24 publications

(25 citation statements)

References 21 publications

(26 reference statements)

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“…In their retrospective cohort study, Kempegowda et al highlighted findings indicating COVID-19 impacts DKA differently in type 1 and type 2 diabetics. 9 Furthermore, type 2 diabetics required greater ICU length of stay and had a higher mortality rate compared to type 1 diabetics who were more hyperglycemic upon presentation. 9 Our study did not include any COVID-19 patients since our enrollment period was between July 2015 to October 2020.…”

Section: Discussionmentioning

confidence: 99%

“…9 Furthermore, type 2 diabetics required greater ICU length of stay and had a higher mortality rate compared to type 1 diabetics who were more hyperglycemic upon presentation. 9 Our study did not include any COVID-19 patients since our enrollment period was between July 2015 to October 2020. Given the increasing incidence of COVID-19, larger prospective multicenter studies are needed to determine if there are any treatment adjustments that need to be made when treating DKA patients with concurrent diagnosis of COVID-19.…”

Section: Discussionmentioning

confidence: 99%

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Comparing the Efficacy of a Nurse-Driven and a Physician-Driven Diabetic Ketoacidosis (DKA) Treatment Protocol

Anis¹,

Boudreau²,

Thornton³

2021

CPAA

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Background: Standardized DKA treatment could result in better overall safety and efficacy outcomes. The primary objective of this study is to validate the efficacy of an adapted nursedriven DKA protocol compared to a physician-driven DKA protocol across the continuum of three hospital settings: the University of Colorado upon which the physician-driven protocol is based, Northern Light Eastern Maine Medical Center (NLEMMC), and Northern Light Sebasticook Valley Hospital (NLSVH). The secondary objective is to assess the safety of the adapted nurse-driven DKA protocol adapted at NLEMMC and NLSVH through determining the incidence of hypoglycemia and anion gap reopening. Patients and Methods: This was a retrospective, IRB-approved, multi-center study that included: patients 18 years or older who were treated with the DKA protocol at NLEMMC or NLSVH, and admitted to the emergency department between July 2015 and October 2020 with a primary diagnosis of DKA and an elevated anion gap greater than or equal to 13 mEq/L. Results: A total of 90 patients from NLEMMC and 64 patients from NLSVH were included and compared to 111 patients from the University of Colorado who were included in the post protocol implementation group. There was no statistically significant difference in the primary outcome, time to anion gap closure, between the original University of Colorado study (10.3 hours) and the NLEMMC (10.9 hours, p = 0.420) and NLSVH (8.8 hours, p = 0.115) results presented in this study. Conclusion:The standardized nurse-driven DKA treatment protocol at NLEMMC and NLSVH showed no statistical difference in time to anion gap closure compared to the University of Colorado study upon which it was based. This finding is particularly relevant to hospitals such as NLEMMC and NLSVH that lack provider resources and teams of endocrinologists required for the physician-driven DKA protocol.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Comparing the Efficacy of a Nurse-Driven and a Physician-Driven Diabetic Ketoacidosis (DKA) Treatment Protocol

Anis¹,

Boudreau²,

Thornton³

2021

CPAA

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“…Inadequate glycaemic control can be a risk factor for the development of diabetic ketoacidosis (DKA), [ 66 ]–[ 68 ] which is typically seen in patients who are volume-depleted as a result of fever and inadequate fluid intake, [ 66 ] symptoms that can occur in Covid-19. By contrast, little is known about hypoglycaemia in patients with Covid-19; in non-Covid-19 settings, hypoglycaemia can be a significant risk factor for poor outcomes in intensive care [ 69 ].…”

Section: Introductionmentioning

confidence: 99%

“…If patients requiring hospitalization for Covid-19 continue on SGLT2i, they should be monitored for DKA, which can occur in patients with Covid-19 independently of treatment, but can sometimes also be associated with SGLT2i use [ 66 ]–[ 68 , 108 ]–[ 116 ]. For patients with Covid-19 who are not hospitalized, we suggest that factors that may increase the risk for DKA are considered, namely fluid loss due to diarrhoea or low intake of food and drink due to a suppressed appetite or gastrointestinal symptoms.…”

Section: Introductionmentioning

confidence: 99%

The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?

Czupryniak

Dicker

Lehmann³

et al. 2021

Cardiovasc Diabetol

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Patients with Covid-19 place new challenges on the management of type 2 diabetes, including the questions of whether glucose-lowering therapy should be adjusted during infection and how to manage a return to normal care after resolution of Covid-19 symptoms. Due to the sudden onset of the pandemic, physicians have by necessity made such important clinical decisions in the absence of robust evidence or consistent guidelines. The risk to patients is compounded by the prevalence of cardiovascular disease in this population, which alongside diabetes is a major risk factor for severe disease and mortality in Covid-19. We convened as experts from the Central and Eastern European region to consider what advice we can provide in the setting of type 2 diabetes and Covid-19, considering the evidence before, during and after infection. We review recommendations that have been published to date, and consider the best available—but currently limited—evidence from large observational studies and the DARE-19 randomized control trial. Notably, we find a lack of guidance on restarting patients on optimal antidiabetic therapy after recovering from Covid-19, and suggest that this may provide an opportunity to optimize treatment and counter clinical inertia that predates the pandemic. Furthermore, we emphasize that optimization applies not only to glycaemic control, but other factors such as cardiorenal protection. While we look forward to the emergence of new evidence that we hope will address these gaps, in the interim we provide a perspective, based on our collective clinical experience, on how best to manage glucose-lowering therapy as patients with Covid-19 recover from their disease and return to normal care.

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“…diabetic ketoacidosis [DKA] or hyperglycaemic hyperosmolar syndrome [HHS]) have been described [1][2][3]. Few studies have directly compared patients in DKA with COVID-19 to those without COVID-19 [4][5][6] and none have specifically studied patients at a safety-net hospital. The objective of this study was to compare the clinical characteristics, management, and outcomes of patients with DKA, HHS, or mixed DKA-HHS and a positive SARS-CoV-2 RT-PCR to negative patients with DKA/HHS from a low-income, racially and ethnically diverse catchment area.…”

Section: Introductionmentioning

confidence: 99%

Some characteristics of hyperglycaemic crisis differ between patients with and without COVID-19 at a safety-net hospital in a cross-sectional study

et al. 2021

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Objective To compare patients with DKA, hyperglycaemic hyperosmolar syndrome (HHS), or mixed DKA-HHS and COVID-19 [COVID (+)] to COVID-19-negative (−) [COVID (−)] patients with DKA/HHS from a low-income, racially/ethnically diverse catchment area. Methods A cross-sectional study was conducted with patients admitted to an urban academic medical center between 1 March and 30 July 2020. Eligible patients met lab criteria for either DKA or HHS. Mixed DKA-HHS was defined as meeting all criteria for either DKA or HHS with at least 1 criterion for the other diagnosis. Results A total of 82 participants were stratified by COVID-19 status and type of hyperglycaemic crisis [26 COVID (+) and 56 COVID (−)]. A majority were either Black or Hispanic. Compared with COVID (−) patients, COVID (+) patients were older, more Hispanic and more likely to have type 2 diabetes (T2D, 73% vs 48%, p < .01). COVID(+) patients had a higher mean pH (7.25 ± 0.10 vs 7.16 ± 0.16, p < .01) and lower anion gap (18.7 ± 5.7 vs 22.7 ± 6.9, p = .01) than COVID (−) patients. COVID (+) patients were given less intravenous fluids in the first 24 h (2.8 ± 1.9 vs 4.2 ± 2.4 L, p = .01) and were more likely to receive glucocorticoids (95% vs. 11%, p < .01). COVID (+) patients may have taken longer to resolve their hyperglycaemic crisis (53.3 ± 64.8 vs 28.8 ± 27.5 h, p = .09) and may have experienced more hypoglycaemia <3.9 mmol/L (35% vs 19%, p = .09). COVID (+) patients had a higher length of hospital stay (LOS, 14.8 ± 14.9 vs 6.5 ± 6.0 days, p = .01) and in-hospital mortality (27% vs 7%, p = .02). Discussion Compared with COVID (−) patients, COVID (+) patients with DKA/HHS are more likely to have T2D. Despite less severe metabolic acidosis, COVID (+) patients may require more time to resolve the hyperglycaemic crisis and experience more hypoglycaemia while suffering greater LOS and risk of mortality. Larger studies are needed to examine whether differences in management between COVID (+) and (−) patients affect outcomes with DKA/HHS.

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Effect of COVID-19 on the clinical course of diabetic ketoacidosis (DKA) in people with type 1 and type 2 diabetes

Cited by 24 publications

References 21 publications

Comparing the Efficacy of a Nurse-Driven and a Physician-Driven Diabetic Ketoacidosis (DKA) Treatment Protocol

Comparing the Efficacy of a Nurse-Driven and a Physician-Driven Diabetic Ketoacidosis (DKA) Treatment Protocol

The management of type 2 diabetes before, during and after Covid-19 infection: what is the evidence?

Some characteristics of hyperglycaemic crisis differ between patients with and without COVID-19 at a safety-net hospital in a cross-sectional study

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