ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of
            <scp>COVID</scp>
            ‐19 and resource‐limited settings‐role of subcutaneous insulin

Priyambada, Leena; Wolfsdorf, Joseph I.; Brink, Stuart; Fritsch, Maria; Codner, Ethel; Donaghue, Kim C.; Craig, Maria E.

doi:10.1111/pedi.13118

Cited by 27 publications

(28 citation statements)

References 32 publications

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“…The unique interactions between SARS-CoV-2 and the RAAS might provide yet another mechanism in the pathophysiology of DKA first by direct entry of SARS-CoV-2 into pancreatic islet cells worsening b-cell injury, and second by downregulation of ACE2 after viral entry that can lead to unopposed angiotensin II and subsequent insulin secretion impedance [56,57]. Moreover, as the relationship between SARS-CoV-2 and the RAAS increases pulmonary vascular permeability and worsens damage to lung parenchyma, fluid replacement needs to be administered judiciously to avoid aggravating pulmonary injury [54,58,59].…”

Section: Discussionmentioning

confidence: 99%

Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis

Papadopoulos

Koutroulos²,

Zikoudi³

et al. 2021

Diabetol Int

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Aims COVID-19 is associated with diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and euglycaemic DKA (EDKA); however, evidence regarding parameters affecting outcome and mortality rates is scarce. Methods A systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January 2020 to 7 January 2021 to identify all studies describing clinical profile, outcome and mortality rates regarding DKA, HHS, DKA/HHS and EDKA cases in COVID-19 patients. The appropriate Joanna Briggs Institute tools were used for quality assessment; quality of evidence was approached using GRADE. Univariate and multivariate analyses were used to assess correlations between clinical characteristics and outcome based on case reports. Combined mortality rates (CMR) were estimated from data reported in case report series, cross-sectional studies, and meta-analyses. The protocol was submitted to PROSPERO (ID: 229356/230737). Results From 312 identified publications, 44 were qualitatively and quantitatively analyzed. Critical COVID-19 necessitating ICU (P = 3 × 10-8), DKA/HHS presence (P = 0.021), and AKI (P = 0.037) were independently correlated with death. Increased COVID-19 severity (P = 0.003), elevated lactates (P < 0.001), augmented anion gap (P < 0.001), and AKI (P = 0.002) were associated with DKA/HHS. SGLT-2i were linked with EDKA (P = 0.004) and negatively associated with AKI (P = 0.023). CMR was 27.1% (95% CI 11.2-46.9%) with considerable heterogeneity (I 2 = 67%). Conclusion Acute diabetes-related metabolic emergencies in COVID-19 patients lead to increased mortality; key determinants are critical COVID-19 illness, coexistence of DKA/HHS and AKI. Previous SGLT-2i treatment, though associated with EDKA, might preserve renal function in COVID-19 patients.

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Section: Discussionmentioning

confidence: 99%

Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis

Papadopoulos

Koutroulos²,

Zikoudi³

et al. 2021

Diabetol Int

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“…Another important aspect in DKA management is that of monitoring and correcting electrolyteabnormalities. As angiotensin II stimulates aldosterone secretion and increases renal potassium loss, this can potentiate the risk of hypokalemia, which might necessitate additional potassium supplementation in order to continue intravenous insulin to suppress ketogenesis[86][87][88][89].…”

mentioning

confidence: 99%

Acute Metabolic Emergencies in Diabetes and COVID-19: a systematic review and meta-analysis of case reports

Papadopoulos¹,

Koutroulos²,

Zikoudi³

et al. 2021

Preprint

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BackgroundCOVID-19 is associated with DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and EDKA (Euglycaemic DKA). High mortality has been observed in COVID-19-related diabetic ketoacidosis; however, evidence is scarce.MethodsA systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January to December 2020 to identify all case reports describing DKA, HHS, and EDKA, in COVID-19 patients. The Joanna Briggs Institute critical appraisal checklist for case reports was used for quality assessment. Univariate and multivariate analysis assessed correlations of study origin, combined DKA/HHS, age, BMI, HbA1c, administered antidiabetics, comorbidities, symptoms onset, disease status (DS), CRP, ferritin, d-dimers, glucose, osmolarity, pH, bicarbonates, ketones, lactates, β-hydroxybutyric acid, anion gap, and acute kidney injury (AKI) with outcome. The relevant protocol was submitted to PROSPERO database (ID: 229356).ResultsFrom 312 identified publications, 41 including 71 cases analyzed qualitatively and quantitatively. The types of acute metabolic emergencies observed were DKA (45/71, 63.4%), EDKA (6/71, 8.5%), combined DKA/HHS (19/71, 26.8%), and HHS (1/71, 1.4%). Overall mortality was 32.4% (22/68 patients; 3 missing). Multivariate analysis by classical regression demonstrated that COVID-19 DS4 (P=3•10−8), presence of DKA/HHS (P=0.021), and development of AKI (P=0.037) were all independently correlated with death. Increased DS (P=0.003), elevated lactates (P<0.001), augmented anion gap (P<0.001), and presence of AKI (P=0.002) were associated with DKA/HHS. SGLT-2i administration was linked with EDKA (P=0.004); however, a negative association with AKI was noted (P=0.023).ConclusionCOVID-19 intertwines with acute metabolic emergencies in diabetes leading to increased mortality. Key determinants are critical COVID-19 illness, coexistence of DKA/HHS and AKI. Awareness of clinicians to timely assess them might enable early detection and immediate treatment commencing. As previous treatment with was negatively associated with AKI, thus implying a prophylactic effect on renal function, the issue of discontinuation of SGLT-2i in COVID-19 patients remains to be further evaluated.Key messagesWhat is already known on this subject▸Diabetes mellitus (DM) is a risk factor for poor outcomes in COVID-19 patients.▸Diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) are not rare in COVID-19 diabetic and non-diabetic patients; key determinants of outcome remain unknown.What this study adds▸COVID-19 intertwines with acute metabolic emergencies in diabetes leading to increased mortality; key determinants are critical COVID-19 illness, coexistence of DKA and HHS as well as development of acute kidney injury.▸SGLT2-i administration is linked with euglycaemic DKA in patients with COVID-19, though preserving renal function.

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Section: Discussionmentioning

confidence: 99%

“…However, these guidelines have been updated during the COVID-19 pandemic to help reduce the burden on the ICU services and teams who are overwhelmed by the number of critically ill COVID-19-infected patients. The new recommendations state that, in case of uncomplicated, mild, and moderate DKA, management could be carried out outside the ICU using subcutaneous insulin (22). It has been thought that the severe acute respiratory syndrome coronavirus 2, which is the causative organism of the COVID-19 pandemic, exerts its effects on various systems, such as the respiratory system, the vascular system, and the gastrointestinal tract, including the intestines and pancreas, by binding to ACE2, a surface receptor found on various body organs.…”

Section: Discussionmentioning

confidence: 99%

Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience

et al. 2022

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BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has been associated with significant challenges pertaining to the management of children and adolescents with type 1 diabetes (T1D). Issues such as fear of infection and lockdown measures have resulted in delayed and more severe clinical presentations of this disease.ObjectivesThis study aimed at reporting the frequency and severity of diabetic ketoacidosis (DKA) and the rate of DKA complications in children with diabetes who presented to the emergency unit during COVID-19 pandemic. Furthermore, the purpose of this study was to compare the data collected from the first and second COVID-19 waves with that of the pre-COVID-19 period and describe the challenges encountered during disease management.MethodsThis cross-sectional study included all children and adolescents with T1D who presented to the emergency department at Abo El Rish Children’s Hospital, Cairo University, during the first and second COVID-19 waves. It also included data collected from the pre-COVID-19 period. Demographic and clinical data, investigations, and management details were collected from the patients’ medical records.ResultsThree hundred twenty-four Egyptian children and adolescents diagnosed with T1D were recruited. One hundred forty patients (43.2%) presented with severe DKA, and approximately 66% were newly diagnosed with T1D. The participants presented with manifestations suggestive of COVID-19, such as fever (29.5%), respiratory manifestations (7.2%), and gastrointestinal symptoms (14.7%). Thirty-seven patients were tested for severe acute respiratory syndrome coronavirus 2 infection using nasopharyngeal swabs, and four patients tested positive. Around 18% of patients developed hypokalemia during disease management. A comparison between these data and the data from previous years revealed that there was a significant increase in the number of newly diagnosed cases with more severe DKA at presentation and a higher frequency of development of hypokalemia during both COVID-19 waves.ConclusionAn increase in the frequency of newly diagnosed cases was identified during the first and the second COVID-19 waves compared with the pre-COVID-19 period. The patients presented with more severe DKA, probably due to a more delayed presentation. The frequency of hypokalemia development was also significantly higher, and the severity of DKA was associated with a longer ICU admission. Further studies are required to establish a definitive link between the COVID-19 pandemic and the severity of presentation.

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ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID ‐19 and resource‐limited settings‐role of subcutaneous insulin

Cited by 27 publications

References 32 publications

Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis

Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis

Acute Metabolic Emergencies in Diabetes and COVID-19: a systematic review and meta-analysis of case reports

Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience

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