Predictors of new-onset diabetic ketoacidosis in patients with moderate to severe COVID-19 receiving parenteral glucocorticoids: A prospective single-centre study among Indian type 2 diabetes patients

Abstract

Background and aim COVID-19 infection predisposes to diabetic ketoacidosis(DKA); whether glucocorticoids enhances this risk is unknown. We aimed to study the occurrence of DKA after initiating glucocorticoids in patients with type 2 diabetes mellitus(T2DM) and moderate-to-severe COVID-19, and identify predictors for it. Methods Patients with T2DM and moderate or severe COVID-19 infection were prospectively observed for development of new-onset DKA for one week following initiation of parenteral dexamethasone. Clinical and biochemical parameters were compared between those who developed DKA (Group A) and those who didnot (Group B). Logistic regression was done to identify independent risk-factors predicting DKA; ROC-curve analysis to determine cut-offs for the parameters in predicting DKA. Results Amongst 302 patients screened, n = 196 were finally included, of whom 13.2% (n = 26,Group A) developed DKA. Patients in Group A were younger, had lower BMI, increased severity of COVID-19 infection, higher HbA1c%, CRP, IL-6, D-dimer and procalcitonin at admission (p all < 0.02). Further, admission BMI (OR: 0.43, CI: 0.27–0.69), HbA1c % (OR: 1.68, CI: 1.16–2.43) and serum IL-6 (OR: 1.02, CI: 1.01–1.03) emerged as independent predictors for DKA. Out of these, IL-6 levels had the highest AUROC (0.93, CI: 0.89–0.98) with a cut-off of 50.95 pg/ml yielding a sensitivity of 88% and specificity of 85.2% in predicting DKA. Conclusion There is significant incidence of new-onset DKA following parenteral glucocorticoids in T2DM patients with COVID-19, especially in those with BMI <25.56 kg/m 2 , HbA1c% >8.35% and IL-6 levels >50.95 pg/ml at admission.

Endocrine and metabolic complications of COVID-19: lessons learned and future prospects

“…Since glucocorticosteroids are used as an effective anti-inflammatory drug in severe COVID-19, it has been discussed receiving corticosteroids in diabetic patients can precipitate the progression of DKA. This study also proposed that the IL-6 level at admission could be a predictive factor for the development of DKA in COVID-19 (Mondal et al 2021).…”

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

“…Among the included studies, 11 reported DKA and COVID-19 in children [ 8 , 11 , 22 , 30 , 34 , 44 , 45 , 56 , 61 , 66 , 72 ], 56 reported DKA and COVID-19 in adults [ 9 , 10 , 12 – 21 , 23 , 25 – 29 , 31 – 33 , 35 – 43 , 46 – 55 , 57 – 60 , 62 – 65 , 67 – 71 , 73 – 75 ], and only 1 study reported DKA and COVID-19 in both children and adults [ 24 ]. There were 54 case report [ 8 – 12 , 14 , 16 , 17 , 19 – 23 , 25 – 27 , 29 – 42 , 44 – 51 , 53 – 58 , 60 , 61 , 64 , 66 , 67 , 69 , 71 , 72 , 74 , 75 ], 10 case series [ 13 , 15 , 28 , 43 , 58 , 59 , 62 , 63 , 70 , 73 ...…”

A Novel Hyperinflammation Clinical Risk Tool, HI5-NEWS2, Predicts Mortality Following Early Dexamethasone Use in an Observational Cohort of Hospitalised COVID-19 Patients

“…This concern has certainly been a factor in the poor overall results of steroid therapy in other viral conditions unless effective anti-viral therapy is given in conjunction. In addition, there is a valid concern supported by anecdotal experience that these individuals may suffer the well-established adverse effects of high dose steroid therapy, including a significant increased risk of new-onset diabetic ketoacidosis (34). New therapies are required in this HI5-NEWS2 low risk group to improve outcomes.…”