Letter to the editor: Unexpected high mortality in COVID-19 and diabetic ketoacidosis

Abstract

Letter to the editor: Unexpected high mortality in COVID-19 and diabetic ketoacidosis To the EditorPatients with diabetes mellitus (DM) appear to be at a greater risk for severe symptoms and complications, including death from 2]. DM is a common comorbidity in patients affected with COVID-19 and may cause ketosis, ketoacidosis, and diabetic ketoacidosis (DKA) [3]. In patients with DM, acute hyperglycemic crises such as DKA and hyperosmolar hyperglycemic state can be precipitated by an acute illness such as COVID-19 and it can result in catastrophic outcomes. At Jacobi Medical Center, an epicenter of the COVID-19 pandemic crisis, we noted that a significant proportion of patients with COVID-19 also presented with DKA. We identified 50 such patients admitted with COVID-19 from March 10th to April 30th of 2020 who concomitantly had DKA upon admission or developed DKA during their hospital course. DKA was defined as blood glucose N250 mg/dL, an elevated anion gap, and positive ketones in blood or urine. COVID-19 was confirmed by real-time reverse-transcription polymerase chain reaction (PCR) assay (BioReference Laboratories, Elmwood Park, NJ).Among the evaluated patients, 32 (64%) were male, the median age was 59 years (IQR 42.3-70), 16 (31%) were Hispanic, 15 (30%) were African American, and the median body mass index (BMI) was 27.15 kg/m 2 (see Table 1). Six of the 50 patients (12%) had a previous diagnosis of Type 1 DM with a median hemoglobin A1C (HbA1C) before the admission of 11%. Forty-four (88%) patients had previously diagnosed type 2 DM and their median HbA1c before the admission was 8.05%. Eight patients (16%) had previously undiagnosed DM. Twenty (40%) patients were on oral hypoglycemic agents with only 2 on SGLT2 inhibitors (which are known to increase the risk of ketoacidosis), 24 (48%) were on a home insulin regimen, and 4 (8%) patients were receiving treatment with GLP-1 agonists.The median value of the initial glucose on presentation in our sample population was 506.5 mg/dL (252.0-1485.0 mg/dL). Forty-three (86%) patients were treated with intravenous insulin infusion protocol and 7 (14%) were treated with subcutaneous insulin protocol. The mean insulin and the intravenous fluids requirements in the first 24 h were 115. 5Author contributions NCP, SP, JA, and PK contributed to the design and implementation of the data collection, and to the analysis of the results. All author's discussed the results and contributed to the final manuscript.

Ferritin in the coronavirus disease 2019 (COVID‐19): A systematic review and meta‐analysis

“…A total of 777 records were collected by the databases and manual searching. After the exclusion of the duplicates, review articles, case reports, pre‐printed versions without peer‐review, and irrelevant studies by title or abstract screening, 187 studies remained for full‐text review; 52 studies 6,17‐67 were finally included into the meta‐analysis, and 18 studies were included in the qualitative synthesis (Figure 1). A total of 52 records involving 10 614 COVID‐19 patients confirmed between December 25, 2019, and June 1, 2020, were included.…”

“…Ten studies were performed in multicenters 6,17,23,34,45,49,57,58,60,64 . Among the included studies, 17 compared the ferritin level between groups with different severity of COVID‐19 18‐22,34,35,37‐39,44,50,53,56,61,64,65 and 18 compared its level between non‐survivors and survivors 6,17,23,24,26‐29,40‐42,45,46,52,55,58,63,66 . The characteristics of all studies included in this meta‐analysis are listed in Table 1.…”

Sodium–Glucose Cotransporter 2 Inhibitors and Major COVID-19 Outcomes: Promising Mechanisms, Conflicting Data, and Intriguing Clinical Decisions

“…The major issue that arises against the use of SGLT2 inhibitors in patients with COVID-19 is the potentially increased risk of diabetic ketoacidosis (DKA) in the context of an acute infection [7,8]. Protracted ketonemia, delay in DKA resolution, and high mortality among patients with COVID-19 and DKA pose significant concerns regarding the use of SGLT2 inhibitors in the acute setting, despite the fact that the rates of SGLT2 inhibitor usage in the aforementioned series were low [9,10].…”

Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature

“…As with other severe infections [ 6 ], diabetic ketoacidosis (DKA) has been reported in patients with COVID-19 [ [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] ]. With regard to coronaviruses, it has been shown that SARS-CoV (responsible for the SARS outbreak in 2003) binds to ACE2 in the pancreatic islets leading to islet damage and acute diabetes [ 25 ].…”

“…The clinical outcome of COVID-19 patients with DKA has been somewhat conflicting across studies; while one study found a mortality rate of 50% in COVID-19 patients with DKA [ 9 ], another study found that patients with DKA were more likely to survive compared to non-DKA patients [ 17 ]. Moreover, patients with combined DKA and HHS tend to have higher mortality than either DKA or HHS alone [ 29 ], however, similar comparative data in COVID-19 is lacking.…”