Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review

A Practice in Maturation: Current Perspectives on the Transition from Pediatric to Adult Care for Young Adults with Diabetes

PURPOSE OF REVIEW

This review of available literature and resources highlights the challenges in transition from pediatric to adult care for young adults with diabetes, summarizes practical recommendations for facilitating the process, and identifies areas for improvement in current transition practice.

RECENT FINDINGS

Observational studies highlight suboptimal transition preparation counseling, gaps between pediatric and adult care, and increased post-transition hemoglobin A1c and acute care utilization. Studies showing improved outcomes with later age at transition allows for an extended focus on transition preparation with an eye toward developmental maturity. Interventional studies suggest varying benefits of transition coordinators and support programs. The period of transition from pediatric to adult care is a time of in which patients are at high risk for adverse outcomes and loss to follow-up; however, careful attention to planning the process and tracking patient readiness along with skilled care coordination can contribute to transition success. The durability of interventional models, as well as generalizability to varied clinical settings, must be further tested.

Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention

Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.

Continuous subcutaneous insulin infusion vs modern multiple injection regimens in type 1 diabetes: an updated meta-analysis of randomized clinical trials

Meta-analyses of clinical trials comparing CSII with traditional insulin injections usually show a small, but significant advantage of CSII with respect to HbA1c and risk of severe hypoglycemia. On the other hand, CSII is associated with a small, but relevant risk of ketoacidosis, mainly due to malfunction of insulin pump and/or catheter occlusion. During last time, the technology of insulin pumps and infusion sets has improved as the profound evolution in type and schemes with traditional insulin injections. Aim of the present study is to update previous meta-analyses comparing CSII with traditional insulin injections in subjects with type 1 diabetes. Specific subgroup analyses were designed for assessing the effects of CSII in comparison with basal-bolus MDI, with short-acting analogues as bolus and long-acting analogues as basal insulin. In addition, an exploratory analysis was performed to verify the effect of CSII in insulin-naïve patients with type 1 diabetes. The present analysis includes all randomized clinical trials comparing CSII with traditional injections in type 1 diabetes, with a duration of at least 12 weeks. Animal studies were excluded, whereas no language or date restriction was imposed. If duplicate publications of a single trial were present, the paper containing more adequate information was considered as principal publication. In trials comparing CSII with basal-bolus MDI, performed before the introduction of rapid-acting analogues, regular human insulin was used for CSII, and as prandial insulin in control groups. CSII was associated with a significant reduction of A1c, in comparison with MDI, irrespective of the use of either human insulin or rapid-acting analogues. However, in trials with rapid-acting analogue the advantage of CSII was significantly smaller than in trials with regular human insulin (HbA1c difference: - 0.29[- 0.46; - 0.13] vs - 1.93[- 1.84; - 0.42]%; p = 0.02). Different rapid-acting analogues provided similar results (HbA1c reduction vs MDI: - 0.25 [- 0.48; - 0.02]%, p = 0.03, and - 0.29 [- 0.49; - 0.09]%, p = 0.005, for lispro and aspart, respectively). In addition, in trials comparing CSII with basal-bolus MDI, CSII reduced HbA1c to a similar extent irrespective of the use of either NPH or long-acting analogues as basal insulin in the control groups (HbA1c reduction vs MDI: - 0.31 [- 0.55; - 0.06]%, p = 0.01, and - 0.20 [- 0.38; - 0.03]%, p = 0.02, for NPH and long-acting analogues, respectively. With respect to severe hypoglycemia, CSII did not produce a significant reduction of risk in comparison with traditional insulin injections. Conversely, CSII was associated with a significant increase in the incidence of reported diabetic ketoacidosis (DKA). Notably, the increased risk of DKA was significant in trials comparing CSII with conventional insulin therapy, whereas only a nonsignificant trend toward an increased risk was observed in comparisons with basal-bolus MDI. Only two trials comparing CSII with basal-bolus MDI, both using rapid-acting analogues, were performed on insulin-naïve type 1 diabetic patients. When those two trials were analyzed separately, CSII did not produce any relevant effect on HbA1c (difference from control: - 0.10[- 0.38; + 0.17]%; p = 0.46). No meta-analysis could be performed on either severe hypoglycemia or DKA, which were not reported by one of the two trials. CSII seems to produce a small improvement in HbA1c in patients with type 1 diabetes inadequately controlled with MDI. This apparent effect, which could be partly due to publication bias, is smaller when MDI is properly performed using basal-bolus schemes with short-acting insulin analogues. Other outcomes different from HbA1c (such as quality of life) could be relevant for the choice of CSII instead of MDI. In addition, further studies are needed to better define the profile of patients who could benefit most from CSII.

Diabetic ketoacidosis in patients with type 2 diabetes treated with sodium glucose co-transporter 2 inhibitors versus other antihyperglycemic agents: An observational study of four US administrative claims databases

Purpose

To compare the incidence of diabetic ketoacidosis (DKA) among patients with type 2 diabetes mellitus (T2DM) who were new users of sodium glucose co‐transporter 2 inhibitors (SGLT2i) versus other classes of antihyperglycemic agents (AHAs).

Methods

Patients were identified from four large US claims databases using broad (all T2DM patients) and narrow (intended to exclude patients with type 1 diabetes or secondary diabetes misclassified as T2DM) definitions of T2DM. New users of SGLT2i and seven groups of comparator AHAs were matched (1:1) on exposure propensity scores to adjust for imbalances in baseline covariates. Cox proportional hazards regression models, conditioned on propensity score‐matched pairs, were used to estimate hazard ratios (HRs) of DKA for new users of SGLT2i versus other AHAs. When I² <40%, a combined HR across the four databases was estimated.

Results

Using the broad definition of T2DM, new users of SGLT2i had an increased risk of DKA versus sulfonylureas (HR [95% CI]: 1.53 [1.31‐1.79]), DPP‐4i (1.28 [1.11‐1.47]), GLP‐1 receptor agonists (1.34 [1.12‐1.60]), metformin (1.31 [1.11‐1.54]), and insulinotropic AHAs (1.38 [1.15‐1.66]). Using the narrow definition of T2DM, new users of SGLT2i had an increased risk of DKA versus sulfonylureas (1.43 [1.01‐2.01]). New users of SGLT2i had a lower risk of DKA versus insulin and a similar risk as thiazolidinediones, regardless of T2DM definition.

Conclusions

Increased risk of DKA was observed for new users of SGLT2i versus several non‐SGLT2i AHAs when T2DM was defined broadly. When T2DM was defined narrowly to exclude possible misclassified patients, an increased risk of DKA with SGLT2i was observed compared with sulfonylureas.

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases

BACKGROUND

Simultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options.

METHODS

Databases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles.

RESULTS

Twenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves' disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves' disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA_1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%).

CONCLUSIONS

Concurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.

Rapid detection and clinical spectrum of the novel influenza H1N1 strain in a diabetic pediatric population

OBJECTIVES

H1N1 infection in diabetic patients is of special concern and serious interest since the virus can place individuals, especially children, at great possible risk of subsequently developing type 1 diabetes. This work aims to describe the demographic characteristics, clinical features, and severity of illness of children with type 1 diabetes mellitus (DM), compare the incidence of pandemic H1N1 virus in children with that of the general pediatric population with influenza-like symptoms, and identify the complications of H1N1 virus infection associated with glycemic control.

METHODS

The present study included 45 children and adolescents with type 1 diabetes, who were subject to clinical and laboratory investigations. Another 30 healthy adolescents and children with a mean age of 10.43 ± 4.38 years were included as a control group. H1N1 reverse-transcriptase quantitative PCR (RT-Q PCR) was tested for H1N1 virus detection.

RESULTS

Diabetic patients positive for (H1N1) showed significantly higher random blood sugar (RBS) levels than diabetic patients negative for (H1N1). Moreover, the H1N1-positive patients had significantly higher hemoglobin (Hb) g/dL, platelet counts, total leukocyte counts (TLCs), and CRP levels. Newly diagnosed patients who were tested positive for (H1N1) and diabetic ketoacidosis (DKA) had significantly higher RBS levels and TLCs than patients who were presented with hyperglycemia.

CONCLUSION

RT-PCR is a rapid and specific method for influenza A (H1N1) virus diagnosis. In addition, early administration of oseltamivir no later than 48 hours after the infection is highly recommended in either diabetic or DKA patients suspected of having H1N1.

Correlation Between Vitamin D Deficiency and Diabetic Ketoacidosis

Both type 1 and type 2 diabetes mellitus have been associated with vitamin D deficiency. Diabetic ketoacidosis, which is a complication of type 1 and, rarely, type 2 diabetes, is also found to be associated with vitamin D levels. This review discusses studies on the correlation between diabetic ketoacidosis and vitamin D levels. Studies show that vitamin D deficiency is associated with the occurrence of diabetic ketoacidosis. Diabetic ketoacidosis is also found to affect vitamin D levels. The possible explanation of diabetic ketoacidosis affecting vitamin D levels is the inactivity of the 1-alpha-hydroxylase enzyme and an increase in the renal excretion of vitamin D binding proteins. The presence of vitamin D receptors on pancreatic beta cells explains the role of vitamin D in the causation of diabetic ketoacidosis.

Skin Problems Due to Treatment with Technology Are Associated with Increased Disease Burden Among Adults with Type 1 Diabetes

BACKGROUND

In a 4-month follow-up survey, we examined whether treatment with continuous subcutaneous insulin infusion (CSII) and/or continuous glucose monitoring (CGM) in adults with type 1 diabetes was associated with sustained skin problems and whether skin problems were associated with diabetes-related emotional distress.

RESEARCH DESIGN AND METHODS

A total of 111 adult patients completed a follow-up questionnaire concerning skin problems as a result of CSII and/or CGM use. The questionnaire included a patient-reported outcome measure, the Problem Areas in Diabetes (PAID) scale.

RESULTS

Current visible skin problems caused by CSII or CGM use were reported by 51 (46.0%) participants, in 34 (66.7%) of whom skin problems had been reported more than 4 months earlier. Seventy-two (64.9%) participants reported skin problems as a result of CSII use, whereas 38 (74.5%) reported skin problems owing to CGM use at some time. Itching was the most prevalent complaint. CSII-related itching was associated with a mean PAID score >20 (P = 0.01), and patients with more than one skin problem had an increased PAID score compared with those with one or no skin problems (P = 0.006).

CONCLUSIONS

More than half patients treated with CSII, CGM, or both had experienced skin problems during 4 months of follow-up that were associated with increased diabetes burden. Skin problems represent a persistent health issue affecting diabetes-specific emotional distress.

Characteristics of hyperglycemic crises in an adult population in a teaching hospital in Colombia

Background

Hyperglycemic crisis are the most serious forms of acute decompensation of diabetes mellitus and require urgent medical attention. The epidemiological data of these conditions in Latin America are scarce and in Colombia unknown, that is why we decided to describe the clinical characteristics and factors associated with the mortality of adults who presented with hyperglycemic crises in a teaching hospital in Colombia.

Materials and methods

Retrospective cohort study of all episodes of hyperglycemic crisis treated in Pablo Tobón Uribe Hospital in a three-year period.

Results

The records of 2233 hospitalization episodes related to diabetes mellitus were review, the prevalence of hyperglycemic crises was 2%, half of the events were diabetic ketoacidosis and 57% of the events occurred in people with type 2 diabetes mellitus, 32% of the events were precipitated by an infection and 27% by and inadequate therapy. The average hospital length of stay was 14 ± 3 days and the mortality rate 2.27%.

Conclusions

In a teaching hospital in Latin America hyperglycemic crises are common, with diabetic ketoacidosis being the most frequent, and in a significant number of cases may be preventable. The hospital length of stay in our population is longer than reported in the literature.

Sotagliflozin, the first dual SGLT inhibitor: current outlook and perspectives

Sotagliflozin is a dual sodium-glucose co-transporter-2 and 1 (SGLT2/1) inhibitor for the treatment of both type 1 (T1D) and type 2 diabetes (T2D). Sotagliflozin inhibits renal sodium-glucose co-transporter 2 (determining significant excretion of glucose in the urine, in the same way as other, already available SGLT-2 selective inhibitors) and intestinal SGLT-1, delaying glucose absorption and therefore reducing post prandial glucose. Well-designed clinical trials, have shown that sotagliflozin (as monotherapy or add-on therapy to other anti-hyperglycemic agents) improves glycated hemoglobin in adults with T2D, with beneficial effects on bodyweight and blood pressure. Similar results have been obtained in adults with T1D treated with either continuous subcutaneous insulin infusion or multiple daily insulin injections, even after insulin optimization. A still ongoing phase 3 study is currently evaluating the effect of sotagliflozin on cardiovascular outcomes (ClinicalTrials.gov NCT03315143). In this review we illustrate the advantages and disadvantages of dual SGLT 2/1 inhibition, in order to better characterize and investigate its mechanisms of action and potentialities.

Sudden death due to diabetic ketoacidosis following power failure of an insulin pump: Autopsy and pump data

PURPOSE

To report a case in which autopsy findings and data from an insulin pump illustrate the course up to the death of a 31-year-old man with a history of type 1 diabetes mellitus who was found dead in his apartment with his insulin pump disassembled and placed in another room.

METHODS

Autopsy findings including histological, toxicological and biochemical examination are presented. Postmortem download of data from the insulin pump gave the history of the pump, which included blood glucose, insulin bolus, carbohydrate intake and the time course in the days to death, and the pump settings were recorded. For this case report, police reports on the death as well as hospital records were also reviewed.

RESULTS

At the patch for the insulin pump, nothing abnormal was found. Biochemical analysis showed glucose of 35 mmoL/L in vitreous humor fluid indicating antemortem hyperglycemia, and ketone bodies in the blood of 11.0 mmoL/L indicating ketoacidosis. Acute pulmonary hemostasis, chronic fat accumulation in the liver and acute fat accumulation in the kidneys were histological detected. There were no signs of late diabetic complications such as nephropathy or cardiovascular disease in the tissues. Insulin pump data showed that after three alarms, a power failure of the pump occurred leading to discontinuing insulin delivery, and about 48 h before the deceased was found dead, his body was depleted of insulin.

CONCLUSION

The cause of death is believed to be diabetic ketoacidosis due to completely lack of insulin because of power failure of the insulin pump, which therefore has been a decisive factor in the cascade of events that led to death. The case is, to our knowledge, the first to illustrate a death caused by diabetic ketoacidosis which is supported by autopsy findings and by data of an insulin pump up to the time of power failure. It is a strong example of usefulness of postmortem download of data from insulin pumps to help determine the cause of death among diabetics. Forensic pathologists should therefore review data and history of the pump systematically.

Assessing and managing the acute complications of diabetes mellitus

Nurses commonly encounter patients with type 1 or type 2 diabetes mellitus in their practice. Management of these conditions requires an in-depth knowledge of blood glucose monitoring. It is essential that nurses are aware of normal blood glucose levels, so that they can respond to complications caused by elevated and reduced blood glucose levels. This article aims to enhance nurses' knowledge of the acute metabolic complications of diabetes, such as diabetic ketoacidosis and hyperosmolar hyperglycaemic state, to assist in their recognition and management in clinical practice. It discusses the causes, pathophysiology and treatment of these complications, which are regarded as potentially life-threatening medical emergencies.

Patient and disease characteristics of adult patients with type 1 diabetes in Germany: an analysis of the DPV and DIVE databases

BACKGROUND

An understanding of the current status of patients with type 1 diabetes mellitus (T1DM) can help to provide appropriate treatment.

METHODS

This was a retrospective analysis of the DIabetes Versorgungs-Evaluation (DIVE) and the Diabetes-Patienten-Verlaufsdokumentation (DPV) databases for Germany.

RESULTS

The analysis included 56,250 people with T1DM (54.2% male), a median age of 36.8 years, and a median diabetes duration of 12.4 years. 15.3% were obese (body mass index ≥ 30kg/m²). Long-acting insulin analogs were used by 53.3%, short-acting analogs by 72.1%, and oral antidiabetic drugs by 4.7%. Patients had a median glycosylated hemoglobin (HbA1c) of 7.8%. There was a drop in HbA1c and an increase in the rate of hypertension, oral antidiabetic drug use, and in the rate of severe hypoglycemia (all p < 0.01) with age. Flash glucose monitoring (FGM) showed the best glucose values with fewer complications compared to other monitoring systems. HbA1c and FBG were lower in patients using a pump versus multiple daily injections (MDIs; 7.7 versus 7.9% and 7.8 versus 8.7 mmol/l; all adjusted p < 0.01). Patients had a lower risk of at least one severe hypoglycemic or DKA episode during the most recent treatment year with pump treatment compared to MDI (9.4% versus 10.5% and 4.7% versus 6.1%, both adjusted p < 0.01).

CONCLUSION

The data demonstrated less-than-optimal glycemic control in the young, an increasing metabolic pattern in T1DM with increasing age, a benefit of FGM to improve HbA1c control and adverse effects, as well as benefits of pump treatment over MDIs.

Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study

OBJECTIVES

We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.

DESIGN

The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome.

SETTING

This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country.

PARTICIPANTS

All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study.

INTERVENTIONS

Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study.

MAIN OUTCOME MEASURES

Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists.

RESULTS

There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration.

CONCLUSION

Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.

Isoproterenol Induced Insulin Resistance Leading to Diabetic Ketoacidosis in Type 1 Diabetes Mellitus

Isoproterenol is known to cause insulin resistance and is often used to treat bradyarrhythmias from atrioventricular block. We report a case of isoproterenol induced diabetic ketoacidosis in a 77-year-old female patient treated with isoproterenol for atrioventricular block prior to insertion of permanent pacemaker. Diabetic ketoacidosis (DKA) developed within hours of starting an isoproterenol drip, and there were no other precipitating factors at that time. DKA resolved quickly after discontinuing isoproterenol and starting insulin drip. DKA is a common complication of diabetes mellitus, with about 140,000 hospital admissions for DKA in 2009. While the rate of DKA has increased by nearly 50% between 1988 and 2009, the rate of mortality has decreased. There are many causes of diabetic ketoacidosis, such as medication noncompliance, infection, pancreatitis, stroke, myocardial infarction, and many others. Isoproterenol may lead to diabetic ketoacidosis by increasing insulin resistance.

Role of vitamin C in diabetic ketoacidosis: Is it ready for prime time?

Diabetic ketoacidosis (DKA) is life-threatening acute metabolic complication of diabetes mellitus (DM) that is characterized by acidosis, ketosis, and hyperglycemia, currently affecting mostly patients under 30 years of age with diabetes mellitus type 1. In both, DM and DKA, a pro-inflammatory state exists. This clinical entity occurs as a result of hyperglycemia-induced disturbances, resulting in an increased oxidative metabolism. For the latter reason, the use of vitamin C seems promising in DKA due to its antioxidant role in reducing the superoxide radicals that are consequence of the oxidative stress. This can decrease the pro-inflammatory state and avoids complications. Vitamin C, or also known as ascorbic acid, has been widely used in several illnesses, such as common cold, tissue healing, fertility, atherosclerosis, cancer prevention, immunity restoration, neuro-degenerative disease and also has been suggested to decrease the risk of DM, and this reason is giving place to believe that vitamin C can have an important role in treating diabetic complications such as DKA. In order to counteract these oxidative disturbances in DKA patients, we analyzed the current data regarding vitamin C and evaluate its role in any type treatment of this complication in the near future.

Autoantibodies to the IA-2 Extracellular Domain Refine the Definition of "A+" Subtypes of Ketosis-Prone Diabetes

OBJECTIVE

Autoantibodies directed against tyrosine phosphatase IA-2 antibody (IA-2 Ab) are diagnostic for autoimmune type 1 diabetes. Conventional assays target the intracellular domain of IA-2. Among patients with ketosis-prone diabetes (KPD), characterized by presentation with diabetic ketoacidosis (DKA), >60% of adults lack three classic islet autoantibodies-IA-2, GAD65, and ZnT8 Abs-associated with type 1 diabetes. We aimed to determine whether apparently autoantibody-negative ("A-") KPD patients possess occult IA-2 Ab directed against full-length IA-2 (IA-2FL) or its extracellular domain (IA-2EC).

RESEARCH DESIGN AND METHODS

We developed an assay that targets IA-2FL and IA-2EC and used it to analyze 288 subjects with A- KPD.

RESULTS

Ten A- KPD patients were positive for IA-2EC Ab (3.5%), and three were also positive for IA-2FL Ab (1.0%), similar to frequencies in type 1 and type 2 diabetes.

CONCLUSIONS

Measurement of IA-2FL Ab and IA-2EC Ab improves the accuracy of the Aβ classification of KPD patients.

Acute Management of Diabetic Ketoacidosis in Adults at 3 Teaching Hospitals in Canada: A Multicentre, Retrospective Cohort Study

OBJECTIVES

Diabetic ketoacidosis (DKA) is a common acute complication of diabetes mellitus and is associated with significant morbidity and mortality. There is currently a paucity of data concerning the Canadian experience with DKA. We aimed to characterize the acute management and course of DKA at several Canadian hospitals.

METHODS

We performed a retrospective cohort study of patients admitted to 3 teaching hospitals in Edmonton, Canada. We extracted clinical and laboratory data from the medical charts of patients admitted to general internal medicine wards or intensive care units with moderate or severe DKA.

RESULTS

We included 103 admissions (84 patients) in our study. The majority (68.9%) had type 1 diabetes and presented with severe DKA (60.2%). In the first 24 h, the median (interquartile range) intravenous fluid received was 7.0 (5.5 to 8.8) litres; 23.3% received a priming insulin bolus, 24.3% received bicarbonate and 91.3% received potassium. Hypoglycemia was relatively rare (5.8%), but hypokalemia was common (41.7%). The median time to anion gap ≤12 mmol/L was 8.8 (6.0 to 12.3) h. In 27.1% of cases, intravenous insulin was stopped prior to subcutaneous insulin administration, with a median of 95 (30 to 310) min elapsing before subcutaneous insulin was given. DKA-related mortality was 2.9%.

CONCLUSIONS

The acute management of DKA was generally aligned with clinical guidelines. Areas for improvement include preventing hypokalemia by proactively increasing potassium repletion, reducing initial insulin boluses, administering subcutaneous insulin before stopping intravenous insulin and administering sodium bicarbonate judiciously. Protocols and preprinted order sets may be helpful, especially in smaller centres.

HbA1c and Hypoglycemia Reductions at 24 and 52 Weeks With Sotagliflozin in Combination With Insulin in Adults With Type 1 Diabetes: The European inTandem2 Study

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of the dual sodium-glucose cotransporter 1 and 2 inhibitor sotagliflozin compared with placebo when combined with optimized insulin in adults with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

In a double-blind, 52-week, international phase 3 trial, adults with T1D were randomized to placebo (n = 258) or once-daily oral sotagliflozin 200 mg (n = 261) or 400 mg (n = 263) after 6 weeks of insulin optimization. The primary outcome was change in HbA_1c from baseline to 24 weeks. The first secondary end point was a composite of the proportion of patients with HbA_1c <7.0%, no episode of severe hypoglycemia, and no episode of diabetic ketoacidosis (DKA) at week 24. Fasting glucose, weight, insulin dose, and safety end points were assessed through 52 weeks.

RESULTS

At 24 weeks, placebo-adjusted changes in HbA_1c from baseline (7.8%) were -0.37% and -0.35% with sotagliflozin 200 and 400 mg, respectively (P < 0.001), and differences were maintained at 52 weeks. At 52 weeks, greater proportions of sotagliflozin-treated patients (200 mg: 25.67%; 400 mg: 26.62%) than placebo-treated patients (14.34%; P ≤ 0.001) met the composite end point, and sotagliflozin 400 mg reduced fasting plasma glucose (-0.87 mmol/L; P = 0.008), weight (-2.92 kg; P < 0.001), and total daily insulin dose (-8.2%; P = 0.001). In a 24-week continuous glucose monitoring (CGM) substudy, postprandial glucose decreased (P ≤ 0.009) and CGM demonstrated up to 3 h more time in the target range of 3.9-10.0 mmol/L with sotagliflozin. Treatment satisfaction increased and diabetes distress decreased with sotagliflozin (P < 0.05 vs. placebo). The frequency of documented hypoglycemia was lower with sotagliflozin, and severe hypoglycemia occurred by week 52 in 13 patients (5.0%), 13 patients (5.0%), and 6 patients (2.3%) treated with placebo and sotagliflozin 200 and 400 mg, respectively. DKA occurred in 0 of 258 patients, 6 of 261 patients (2.3%), and 9 of 263 patients (3.4%) in these respective groups.

CONCLUSIONS

In a 1-year study, sotagliflozin was associated with statistically significant HbA_1c reductions. More episodes of DKA and fewer episodes of documented and severe hypoglycemia were observed in patients using sotagliflozin relative to those receiving placebo (ClinicalTrials.gov, NCT02421510).

Challenges in investigation of diabetes-related aviation fatalities-an analysis of 1491 subsequent aviation fatalities in USA during 2011-2016

Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau's database between years 2011-2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (~ 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.

Glucose-responsive insulin delivery for type 1 diabetes: The artificial pancreas story

Insulin replacement therapy is integral to the management of type 1 diabetes, which is characterised by absolute insulin deficiency. Optimal glycaemic control, as assessed by glycated haemoglobin, and avoidance of hyper- and hypoglycaemic excursions have been shown to prevent diabetes-related complications. Insulin pump use has increased considerably over the past decade with beneficial effects on glycaemic control, quality of life and treatment satisfaction. The advent and progress of ambulatory glucose sensor technology has enabled continuous glucose monitoring based on real-time glucose levels to be integrated with insulin therapy. Low glucose and predictive low glucose suspend systems are currently used in clinical practice to mitigate against hypoglycaemia, and provide the first step towards feedback glucose control. The more advanced technology approach, an artificial pancreas or a closed-loop system, gradually increases and decreases insulin delivery in a glucose-responsive fashion to mitigate against hyper- and hypoglycaemia. Randomised outpatient clinical trials over the past 5 years have demonstrated the feasibility, safety and efficacy of the approach, and the recent FDA approval of the first single hormone closed-loop system establishes a new standard of care for people with type 1 diabetes.