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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024:10.1007/s00125-024-06183-8. [PMID: 38907161 DOI: 10.1007/s00125-024-06183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 06/23/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Georgia M Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nuha A ElSayed
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Robert A Gabbay
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
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González-Vidal T, Lambert C, García AV, Villa-Fernández E, Pujante P, Ares-Blanco J, Menéndez Torre E, Delgado-Álvarez E. Hypoglycemia during hyperosmolar hyperglycemic crises is associated with long-term mortality. Diabetol Metab Syndr 2024; 16:83. [PMID: 38594758 PMCID: PMC11005231 DOI: 10.1186/s13098-024-01329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Previous research has indicated that hypoglycemia during hospitalization is a predictor of unfavorable outcomes in patients with diabetes. However, no studies have examined the long-term impact of hypoglycemia in adults admitted for hyperglycemic crises. The study was aimed to investigate the long-term implications of hypoglycemia during hyperosmolar hyperglycemic crises, particularly in terms of all-cause mortality. METHODS This retrospective cohort study included 170 patients (82 men [48.2%], median age 72 years) admitted to a university hospital for hyperosmolar hyperglycemic crises, including pure hyperosmolar hyperglycemic states and hyperosmolar diabetic ketoacidoses. We separately investigated the prognostic significance of hypoglycemia on mortality during the initial intravenous insulin therapy phase and during the later subcutaneous insulin therapy phase, both during hospitalization and in the long term (median follow-up, 652 days; range 2-3460 days). RESULTS Both hypoglycemia during the initial intravenous insulin therapy phase (observed in 26.5% of patients) and hypoglycemia during the later subcutaneous insulin therapy phase (observed in 52.7% of patients) were associated with long-term mortality. After adjusting for potential confounders, hypoglycemia during the initial intravenous insulin therapy phase remained associated with mortality (hazard ratio 2.10, 95% CI 1.27-3.46, p = 0.004). CONCLUSIONS Hypoglycemia during hyperosmolar hyperglycemic crises is a marker of long-term mortality, especially when it occurs during the initial intravenous insulin therapy phase.
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Affiliation(s)
- Tomás González-Vidal
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain.
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.
| | - Carmen Lambert
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ana Victoria García
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Elsa Villa-Fernández
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Pedro Pujante
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Jessica Ares-Blanco
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Department of Medicine, University of Oviedo, Oviedo, Spain
| | - Edelmiro Menéndez Torre
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Department of Medicine, University of Oviedo, Oviedo, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elías Delgado-Álvarez
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Department of Medicine, University of Oviedo, Oviedo, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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Wu Z, Wang J, Ullah R, Chen M, Huang K, Dong G, Fu J. Covid 19 and diabetes in children: advances and strategies. Diabetol Metab Syndr 2024; 16:28. [PMID: 38287388 PMCID: PMC10823738 DOI: 10.1186/s13098-024-01267-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/14/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Throughout the COVID-19 pandemic, there has been a notable increase in the incidence of new-onset diabetes and diabetic ketoacidosis (DKA). Simultaneously, children diagnosed with type 1 diabetes (T1D) have encountered difficulties in maintaining optimal blood glucose levels. The mechanisms underpinning these correlations still remain a puzzle. We reviewed the studies that examined changes in incidence during the pandemic. These studies utilized various metrics for comparison, which encompassed the timing of data collection, diagnostic criteria, as well as the numbers and incidence rates of diabetes and DKA. We found the incidence of diabetes and DKA was higher during the pandemic. As to mechanisms, the invivo and invitro study revealed the factors such as direct viral damage, metabolic dysfunction, and immune responses all attribute to the process of T1D after suffering from COVID-19. Furthermore, we provide some useful strategies to prevent and treat children suffering from diabetes and COVID-19. CONCLUSIONS Strong correlations have been observed between new-onset diabetes and COVID-19. Insights gleaned from clinical descriptions and basic research can offer valuable experience and recommendations for the treatment and prevention of diabetes during future pandemics.
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Affiliation(s)
- Zhaoyuan Wu
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jinling Wang
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Rahim Ullah
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Minghao Chen
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guanping Dong
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Junfen Fu
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.
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Wang J, Yang X, Shen L, Ni R, Huang Y, Sui Z, Wang X. A new turn-on fluorescent probe for fast detection of diabetic biomarker beta-hydroxybutyrate in vitro. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2024; 304:123437. [PMID: 37742589 DOI: 10.1016/j.saa.2023.123437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023]
Abstract
Beta-hydroxybutyrate (β-HB) serve as a valuable diagnostic biomarker for Diabetic Ketoacidosis (DKA). Here, a new Schiff base fluorescent probe T was designed and synthesized to detect β-HB level in aqueous solution in vitro. The probe T can detect β-HB sensitively and selectively in DMF solution (5.0 × 10-5 M) among other interfering species (cations, anions, amino acids, biomarkers). The detection limit of probe T for β-HB was calculated to be 0.154 μM. These results demonstrate that the probe T may provide a convenient method for rapid detection of β-HB to diagnose diabetic ketoacidosis.
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Affiliation(s)
- Jin Wang
- School of Pharmacy, Jiangsu Province Engineering Research Center of Tumor Targeted Nano Diagnostic and Therapeutic Materials, Yancheng Teachers University, Yancheng 224007, Jiangsu Province, China.
| | - Xiaoqin Yang
- School of Pharmacy, Jiangsu Province Engineering Research Center of Tumor Targeted Nano Diagnostic and Therapeutic Materials, Yancheng Teachers University, Yancheng 224007, Jiangsu Province, China
| | - Leilei Shen
- School of Pharmacy, Jiangsu Province Engineering Research Center of Tumor Targeted Nano Diagnostic and Therapeutic Materials, Yancheng Teachers University, Yancheng 224007, Jiangsu Province, China
| | - Ruiyao Ni
- School of Pharmacy, Jiangsu Province Engineering Research Center of Tumor Targeted Nano Diagnostic and Therapeutic Materials, Yancheng Teachers University, Yancheng 224007, Jiangsu Province, China
| | - Yijie Huang
- School of Pharmacy, Jiangsu Province Engineering Research Center of Tumor Targeted Nano Diagnostic and Therapeutic Materials, Yancheng Teachers University, Yancheng 224007, Jiangsu Province, China
| | - Zhaosong Sui
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500, China
| | - Xiaohan Wang
- Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming 650500, China
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Agarwal A, Bansal D, Nallasamy K, Jayashree M, William V. Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt. Pediatric Health Med Ther 2023; 14:281-288. [PMID: 37691882 PMCID: PMC10488656 DOI: 10.2147/phmt.s384104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023] Open
Abstract
The coronavirus disease (COVID-19) pandemic affected the management and follow-up of several chronic ailments, including pediatric type 1 diabetes mellitus (T1DM). Restricted access to healthcare and fear of contracting the virus during medical facility visits resulted in poor compliance, irregular follow-up visits, treatment, and delayed diagnosis of complications in pediatric diabetes such as diabetic ketoacidosis (DKA). As such, the incidence of complicated DKA in resource-limited settings is high due to delayed presentation, poor compliance with therapy, and associated comorbidities such as malnutrition and sepsis. The pandemic had only added to the woes. The increased surge in DKA, in the face of limited resources, prompted clinicians to find alternative solutions to manage these children effectively. In this narrative review, we discuss the key challenges faced globally while caring for children with T1DM and DKA during the COVID-19 pandemic, and the lessons learned thereof.
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Affiliation(s)
- Ashish Agarwal
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Deepankar Bansal
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Vijai William
- Division of Pediatric Critical Care, Department of Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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Griffey RT, Schneider RM, Girardi M, Yeary J, McCammon C, Frawley L, Ancona R, Cruz-Bravo P. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. Acad Emerg Med 2023; 30:800-808. [PMID: 36775281 DOI: 10.1111/acem.14685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/09/2022] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Studies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non-intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics. METHODS We implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann-Whitney U to test for differences in EDLOS distributions, bootstrapped (n = 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions. RESULTS We identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (-3.0, 95% CI -8.5 to -1.4), the preintervention period (-1.4, 95% CI -3.1 to -0.1), and the pre-COVID control period (-3.6, 95% CI -7.5 to -1.8). CONCLUSIONS In this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.
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Affiliation(s)
- Richard T Griffey
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ryan M Schneider
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Margo Girardi
- Department of Internal Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Julianne Yeary
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Craig McCammon
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Laura Frawley
- Barnes-Jewish Hospital Emergency Department, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Rachel Ancona
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
| | - Paulina Cruz-Bravo
- Department of Internal Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
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Cengiz E, Danne T, Ahmad T, Ayyavoo A, Beran D, Ehtisham S, Fairchild J, Jarosz-Chobot P, Ng SM, Paterson M, Codner E. ISPAD Clinical Practice Consensus Guidelines 2022: Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1277-1296. [PMID: 36537533 DOI: 10.1111/pedi.13442] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Eda Cengiz
- University of California San Francisco (UCSF) Pediatric Diabetes Program, UCSF School of Medicine, San Francisco, California, USA
| | - Thomas Danne
- Auf Der Bult, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Tariq Ahmad
- Pediatric Endocrinology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Ahila Ayyavoo
- Department of Pediatrics, G. Kuppuswamy Naidu Memorial Hospital, Coimbatore, India
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Faculty of Medicine University of Geneva and Geneva University Hospitals, Faculty of Medicine Diabetes Centre, Geneva, Switzerland
| | - Sarah Ehtisham
- Division of Pediatric Endocrinology, Mediclinic City Hospital, Dubai, UAE
| | - Jan Fairchild
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, North Adelaide, Australia
| | | | - Sze May Ng
- Paediatric Department, Southport and Ormskirk NHS Trust, Southport, UK.,Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Megan Paterson
- John Hunter Children's Hospital, HRMC, New South Wales, Australia
| | - Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile
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Phelan H, Hanas R, Hofer SE, James S, Landry A, Lee W, Wood JR, Codner E. Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:912-925. [PMID: 36093857 DOI: 10.1111/pedi.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Helen Phelan
- Pediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla Hospital, Uddevalla, and Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Alanna Landry
- Department of Paediatrics, Oak Valley Health, Markham, Ontario, Canada
| | - Warren Lee
- Dr. Warren Lee's Paediatrics, Growth & Diabetes Centre, and KK Hospital, Singapore, Singapore
| | - Jamie R Wood
- University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile
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9
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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11
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Koufakis T, Dhatariya KK, Kotsa K. Potential Role of Ultrafast-acting Insulin Analogues in the Treatment of Diabetic Ketoacidosis. J Clin Endocrinol Metab 2022; 107:e4259-e4260. [PMID: 35552422 PMCID: PMC9516099 DOI: 10.1210/clinem/dgac301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK
- Department of Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, NR4 7UY, UK
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, NR4 7UY, UK
| | - Kalliopi Kotsa
- Correspondence: Kalliopi Kotsa, MD, MMedSci, PhD, Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St Kiriakidi St, 54636, Thessaloniki, Greece.
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12
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Bacha T, Shiferaw Y, Abebaw E. Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia. Endocrinol Diabetes Metab 2022; 5:e363. [PMID: 36102127 PMCID: PMC9471591 DOI: 10.1002/edm2.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration. METHODS A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients. RESULT Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death. CONCLUSION The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.
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Affiliation(s)
- Tigist Bacha
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesSt Paul Millennium Medical CollegeAddis AbabaEthiopia
| | - Yemisrach Shiferaw
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Ermias Abebaw
- Department of Pediatrics and Child Health, School of MedicineDebre Markos UniversityDebre MarkosEthiopia
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13
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Bali IA, Al-Jelaify MR, AlRuthia Y, Mulla JZ, Amlih DF, Bin Omair AI, Al Khalifah RA. Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children. JAMA Netw Open 2022; 5:e2230043. [PMID: 36066894 PMCID: PMC9449786 DOI: 10.1001/jamanetworkopen.2022.30043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Intravenous (IV) insulin infusion is the standard of care for treating diabetic ketoacidosis (DKA) worldwide. Subcutaneous (SC) insulin aspart could decrease the use of health care resources. OBJECTIVE To compare the cost-effectiveness of mild uncomplicated DKA management with SC insulin aspart vs IV insulin infusion among pediatric patients from the perspective of a public health care payer using clinical data. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation included children aged 2 to 14 years presenting to the emergency department of a single academic medical center with mild DKA between January 1, 2015, and March 15, 2020. The medical records for DKA treatment course and its associated hospitalization costs were reviewed. Data were analyzed from January 1, 2015, to March 15, 2020. EXPOSURES Subcutaneous insulin aspart vs IV regular insulin infusion. MAIN OUTCOMES AND MEASURES The incremental cost-effectiveness ratio (US dollars per hour), duration of DKA treatment, and length of hospital stay. RESULTS A total of 129 children with mild DKA episodes (mean [SD] age, 9.9 [3.1] years; 72 girls [55.8%]) were enrolled in the study. Seventy children received SC insulin aspart and 59 received IV regular insulin. Overall, the length of hospital stay in the SC insulin group was reduced (mean, 16.9 [95% CI, -31.0 to -2.9] hours) compared with the IV insulin group (P = .005). The mean (SD) cost of hospitalization in the SC insulin group (US $1071.99 [US $523.89]) was less than that in the IV insulin group (US $1648.90 [US $788.03]; P = .001). The incremental cost-effectiveness ratio was -34.08 (95% CI, -25.97 to -129.82) USD/h. The use of SC insulin aspart was associated with a lower likelihood of prolonged hospital stay (β = -17.22 [95% CI, -32.41 to -2.04]; P = .03) than IV regular insulin when controlling for age and sex. CONCLUSION AND RELEVANCE Findings of this economic evaluation suggest that SC insulin aspart is dominant vs IV regular insulin in the management of mild uncomplicated DKA in children.
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Affiliation(s)
- Ibrahim Abdulaziz Bali
- Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Jaazeel Zohair Mulla
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Dana Fawzi Amlih
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Reem Abdullah Al Khalifah
- Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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14
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Yoo MS, Daniels A, Maslow RA, Gomez JA, Meyers NL, Bohrer PS, Nemazie S, Sanford CE, Peterson EA, Hamann KL, Walsh DE, O’Herlihy AM, Kumra V. Management of hospitalized patients with mild to moderate diabetic ketoacidosis using a continuous insulin infusion protocol on a medical surgical ward and observation level of care: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e29665. [PMID: 35945801 PMCID: PMC9351868 DOI: 10.1097/md.0000000000029665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Although the practice of using rapid-acting subcutaneous insulin for the management of mild-to-moderate diabetic ketoacidosis is becoming increasingly popular, the continuous insulin infusion remains widely utilized, and its real-world applicability and safety on a medical surgical unit (Med Surg) and observation level of care are unclear. We assessed whether a continuous insulin infusion protocol for mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care over a 6.5-year period was associated with adverse outcomes. A retrospective cohort study of adults hospitalized with mild-to-moderate diabetic ketoacidosis was conducted at 2 community hospitals in Northern California, USA, from January 2014 to May 2020. Demographic and clinical variables were collected using an electronic health record. Admission to Med Surg/observation was compared to intensive care unit admission for the outcomes of 30-day readmission, presence of hypoglycemia, rate of hypoglycemic episodes, in-hospital and 30-day mortality, and length of stay using bivariate analysis. Among 227 hospital encounters (mean age 41 years, 52.9% women, 79.3% type 1 diabetes, 97.4% utilization of continuous insulin infusion), 19.4% were readmitted within 30 days, and 20.7% developed hypoglycemia. For Med Surg/observation encounters compared to the intensive care unit, there were no statistically significant differences in the risk of readmission (RR 1.48, 95% CI, 0.86-2.52), hypoglycemia (RR 1.17, 95% CI, 0.70-1.95), or increased length of stay (RR 0.71, 95% CI, 0.55-1.02); there was a lower risk of hypoglycemic events during hospitalization (RR 0.69, 95% CI, 0.54-0.96). Continuous insulin infusion utilization may be a safe option for treatment of mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care. Further investigation is needed.
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Affiliation(s)
- Michael S. Yoo
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
- *Correspondence: Michael S. Yoo, Kaiser Permanente Santa Rosa Medical Center, 401 Bicentennial Way, Santa Rosa, CA 95403, USA (e-mail: )
| | - Abraham Daniels
- Department of Medical Administration Strategic Activities, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Rene A. Maslow
- Department of Critical Care, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - John A. Gomez
- Department of National Quality, Safety, Experience and Health Systems Performance, Kaiser Permanente, Oakland, CA, USA
| | - Nannette L. Meyers
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Pamela S. Bohrer
- Department of Head and Neck Surgery, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Siamack Nemazie
- Department of Nephrology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Christina E. Sanford
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Emily A. Peterson
- Department of Inpatient Pharmacy Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Kendal L. Hamann
- Department of Endocrinology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Darcy E. Walsh
- Department of Oncology and Adult Infusion, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Alison M. O’Herlihy
- Department of Clinical Adult Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
| | - Vivek Kumra
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, CA, USA
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15
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:398-400. [DOI: 10.1093/ijpp/riac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 05/06/2022] [Indexed: 11/12/2022]
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16
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Rajpal A, Sayyed Kassem L, Aron DC. Management of diabetes in elderly patients during the COVID-19 pandemic: current and future perspectives. Expert Rev Endocrinol Metab 2021; 16:181-189. [PMID: 34096441 DOI: 10.1080/17446651.2021.1927708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/06/2021] [Indexed: 02/09/2023]
Abstract
Introduction: The COVID-19 pandemic has affected the entire population with the most deleterious effects in elders. Elders, especially those with diabetes, are at the highest risk of COVID-19 related adverse outcomes and mortality. This is usually linked to the comorbidities that accumulate with age, diabetes-related chronic inflammation, and the pandemic's psychosocial effects.Areas covered: We present some approaches to manage these complicated elderly patients with diabetes during the COVID-19 pandemic. In the inpatient setting, we suggest similar (pre-pandemic) glycemic targets and emphasize the importance of using IV insulin and possible use of continuous glucose monitoring to reduce exposure and PPE utilization. Outside the hospital, we recommend optimal glycemic control within the limits imposed by considerations of safety. We also describe the advantages and challenges of using various technological platforms in clinical care.Expert opinion: The COVID-19 pandemic has lifted the veil off serious deficiencies in the infrastructures for care at both the individual level and the population level and also highlighted some of the strengths, all of which affect individuals with diabetes and COVID-19. We anticipate that things will not return to 'normal' after the COVID-19 pandemic has run its course, but rather they will be superseded by 'New Normal.'
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Affiliation(s)
- Aman Rajpal
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Laure Sayyed Kassem
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - David C Aron
- Endocrine Section, Department of Medicine, Louis Stokes VA Medical Center, Cleveland, OH
- Division of Clinical and Molecular Endocrinology, Department of Medicine, Case Western Reserve University, Cleveland, OH
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17
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Chow L, Valesky W. Subcutaneous Rapid-acting Insulin Analogs for Diabetic Ketoacidosis. Acad Emerg Med 2021; 28:700-702. [PMID: 33145848 DOI: 10.1111/acem.14170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Lillian Chow
- From the Department of Medicine Division of Pulmonary and Critical Care Medicine SUNY Downstate Health Sciences University Brooklyn NY USA
| | - Walter Valesky
- and the Department of Emergency Medicine Kings County Hospital–NYC Health + Hospitals Brooklyn NY USA
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18
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Zeugswetter FK, Luckschander-Zeller N, Karlovits S, Rand JS. Glargine versus regular insulin protocol in feline diabetic ketoacidosis. J Vet Emerg Crit Care (San Antonio) 2021; 31:459-468. [PMID: 33945208 PMCID: PMC8360016 DOI: 10.1111/vec.13062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 12/24/2022]
Abstract
Objectives To determine whether basal‐bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI) protocol. Design Prospective randomized clinical trial. Setting University teaching hospital. Animals Twenty cats diagnosed with diabetic ketoacidosis (DKA). Interventions The cats were block‐randomized to either a CRI protocol using regular insulin (CRI‐group; n = 10) or a basal‐bolus SC and IM glargine protocol (glargine‐group, n = 10). Baseline blood gases, electrolytes, glucose, and β‐hydroxybutyrate (β‐OHB) concentrations were measured at the time of admission and later at predefined intervals until reaching the primary endpoint of the study, defined as a β‐hydroxybutyrate concentration < 2.55 mmol/L. Measurements and main results The main outcome measure was time (h) to resolution of ketonemia. Secondary outcome measures were time until first improvement of hyperglycemia and ketonemia, decrease of glucose to ≤13.9 mmol/L (250 mg/dL), resolution of acidosis, consumption of first meal, and discharge from hospital. Additionally, occurrence of treatment‐associated adverse events and death were compared. Seventeen cats (85%) survived to discharge, with no difference in survival between groups (P = 1.0). Median times to β‐OHB < 2.55 mmol/L were 42 (CRI‐group) and 30 (glargine‐group) hours, respectively (P = 0.114). Median times to first improvement of hyperglycemia (glargine‐group: 2 h; CRI‐group: 6 h; P = 0.018) and until discharge from hospital (glargine‐group: 140 h; CRI‐group: 174 h; P = 0.033) were significantly shorter in the glargine‐group. No significant differences were observed in any other parameter under investigation (P > 0.05). Conclusions Basal‐bolus administration of glargine insulin appears to be an effective and safe alternative to the current standard CRI‐protocol for the management of DKA in cats. The positive outcomes and simplicity make it a viable option for the treatment of feline DKA.
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Affiliation(s)
- Florian K Zeugswetter
- University Hospital for Small Animals of the University of Veterinary Medicine, Vienna, Austria
| | | | - Sonja Karlovits
- University Hospital for Small Animals of the University of Veterinary Medicine, Vienna, Austria
| | - Jaquie S Rand
- School of Veterinary Science, The University of Queensland, Australia
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19
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Mohamed A, Ploetz J, Hamarshi MS. Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis. Curr Diabetes Rev 2021; 17:e030221191986. [PMID: 33655870 DOI: 10.2174/1573399817666210303095633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. OBJECTIVES To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. METHODS This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. RESULTS Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76-37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8-36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04-7.92; p<0.0001). CONCLUSION Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion.
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Affiliation(s)
- Adham Mohamed
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Jeannette Ploetz
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Majdi S Hamarshi
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
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20
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Hishida Y, Nakamura Y, Tsukiyama H, Nakagawa T, Sone M. A retrospective cohort study for the treatment of Asian diabetic ketoacidosis: optimizing initial doses of insulin. Acute Med Surg 2021; 8:e721. [PMID: 34976402 PMCID: PMC8705869 DOI: 10.1002/ams2.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Aim An insulin dose of 0.1 U/kg/h recommended by Western guidelines occasionally induces a precipitous decreasing blood glucose in Asian diabetic ketoacidosis (DKA). It is known that clinical factors, such as insulin sensitivity, differ between Asians and Americans/Europeans. We investigated how treatment options affect the time to DKA resolution to determine the optimal treatment for Asian DKA patients. Methods This was a retrospective cohort study from a single institution in Japan. A total of 34 adult DKA patients were observed. Baseline characteristics and treatment‐related parameters were compared between patients whose DKA was resolved within 18 h and those in which it was not. Results Significant differences were observed in the initial insulin dose (mean [standard deviation]: 0.053 [0.021] versus 0.031 [0.014] U/kg/h; P = 0.003) and the baseline β‐hydroxybutyrate (7.2 [3.2] versus 9.9 [2.6] mmol/L; P = 0.024) and HCO3− levels (11.2 [4.1] versus 7.7 [3.1] mmol/L; P = 0.014). Multivariable logistic regression analysis revealed that the initial insulin dose was significantly associated with early resolution of DKA and was independent of basal conditions. Receiver operating characteristic curve analysis indicated that the optimal cut‐off point for the initial insulin dose was 0.051 U/kg/h. With an initial insulin dose of 0.051 U/kg/h or higher, early resolution of DKA was obtained in 92.9% of patients. Conclusion An initial insulin dose of more than 0.05 U/kg/h provides an early resolution of DKA in Asian patients. Lower insulin doses significantly delay resolution. These results provide practical information for acute phase treatment of Asian DKA.
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Affiliation(s)
- Yoshiaki Hishida
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Yuta Nakamura
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Hidekazu Tsukiyama
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Tomoko Nakagawa
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan
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21
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Priyambada L, Wolfsdorf JI, Brink SJ, Fritsch M, Codner E, Donaghue KC, Craig ME. ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes 2020; 21:1394-1402. [PMID: 32935435 DOI: 10.1111/pedi.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/19/2020] [Accepted: 08/19/2020] [Indexed: 01/08/2023] Open
Abstract
The International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guideline 2018 for management of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state provide comprehensive guidance for management of DKA in young people. Intravenous (IV) infusion of insulin remains the treatment of choice for treating DKA; however, the policy of many hospitals around the world requires admission to an intensive care unit (ICU) for IV insulin infusion. During the coronavirus 2019 (COVID-19) pandemic or other settings where intensive care resources are limited, ICU services may need to be prioritized or may not be appropriate due to risk of transmission of infection to young people with type 1 or type 2 diabetes. The aim of this guideline, which should be used in conjunction with the ISPAD 2018 guidelines, is to ensure that young individuals with DKA receive management according to best evidence in the context of limited ICU resources. Specifically, this guideline summarizes evidence for the role of subcutaneous insulin in treatment of uncomplicated mild to moderate DKA in young people and may be implemented if administration of IV insulin is not an option.
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Affiliation(s)
- Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stuart J Brink
- New England Diabetes and Endocrinology Center, Waltham, Massachusetts, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - Kim C Donaghue
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Maria E Craig
- Sydney Children's Hospital Network, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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22
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Wallia A, Prince G, Touma E, El Muayed M, Seley JJ. Caring for Hospitalized Patients with Diabetes Mellitus, Hyperglycemia, and COVID-19: Bridging the Remaining Knowledge Gaps. Curr Diab Rep 2020; 20:77. [PMID: 33244614 PMCID: PMC7690847 DOI: 10.1007/s11892-020-01366-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This review discusses the interplay between coronavirus disease 2019 (COVID-19, caused by SARS-CoV-2 infection), diabetes mellitus, and hyperglycemia in the hospital setting. There are data emerging about diabetes and hyperglycemia, their prevalence, and potential risks in the setting of SARS-CoV-2 infection and COVID-19. RECENT FINDINGS It is known that viral infections exert effects on beta cell function and insulin resistance. Therefore, much can be learned about SARS-CoV-2/COVID-19 from examining these known relationships. Such pathophysiological underpinnings may unlock greater understanding as we navigate atypical cases of hyperglycemia, severe insulin resistance, and diabetic ketoacidosis amidst COVID-19. Glycemic outcomes likely have beneficial effects on morbidity and mortality, but this needs to be studied. Changes in diabetes-related protocols and new technology can be deployed in the inpatient setting to potentially improve healthcare worker and patient safety; however, one must weigh the risks and benefits of implementation during a pandemic. Ultimately, knowledge and research must be shared at record speed to combat this global crisis.
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Affiliation(s)
- Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Institute of Public Health, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Grace Prince
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emilie Touma
- Institute of Public Health, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Malek El Muayed
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, NY, USA
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23
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Malerba E, Alessandrini F, Grossi G, Giunti M, Fracassi F. Efficacy and Safety of Intramuscular Insulin Lispro vs. Continuous Intravenous Regular Insulin for the Treatment of Dogs With Diabetic Ketoacidosis. Front Vet Sci 2020; 7:559008. [PMID: 33195532 PMCID: PMC7596346 DOI: 10.3389/fvets.2020.559008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/14/2020] [Indexed: 11/23/2022] Open
Abstract
The use of rapid-acting insulin analogs as routes of administration other than IV has never been described for the treatment of dogs with diabetic ketoacidosis (DKA). This study aims to compare the efficacy and safety of a new protocol based on IM administration of insulin lispro with that of low-dose IV continuous rate infusion of regular insulin in the treatment of canine DKA. Client-owned dogs with naturally occurring DKA were included. Dogs treated with IM insulin lispro (Group L, n = 11) received 0.25 U/kg. The goal was to achieve a drop of at least 10% in blood glucose between 1 h and the next. If this goal was not achieved, the insulin dose was repeated hourly; otherwise, the insulin dose was not repeated up to a maximum of 3 h, after which the insulin dose was repeated anyway. When blood glucose was ≤250 mg/dL, the insulin dose was reduced to 0.125 U/kg IM every 3 h. Cases receiving IV continuous rate infusion of regular insulin (Group R, n = 13) were treated according to a previously published protocol. The median time to resolution of ketosis was significantly shorter in Group L (12 h; range, 4–27 h) compared to Group R (23 h; 10–46 h; P = 0.04). The median times to resolution of acidemia and ketoacidosis were 13 h (4–35 h) and 17.5 h (4–35 h) in Group L, and 22 h (9–80 h) and 23.5 h (10–80 h) in Group R, respectively. These differences were not significant (P = 0.06 and P = 0.09, respectively). The median length of hospitalization did not differ significantly between groups (P = 0.67). There were no differences in the frequency and severity of adverse events (hypoglycemia, hypokaliemia, and hypophosphatemia) between groups. The new protocol based on IM administration of insulin lispro preliminarily appears effective and safe for treatment of canine DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | | | - Giorgio Grossi
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
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24
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Lundholm MD, Poku C, Emanuele N, Emanuele MA, Lopez N. SARS-CoV-2 (COVID-19) and the Endocrine System. J Endocr Soc 2020; 4:bvaa144. [PMID: 33145472 PMCID: PMC7543511 DOI: 10.1210/jendso/bvaa144] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/23/2020] [Indexed: 01/08/2023] Open
Abstract
As SARS-CoV-2 (COVID-19) overtakes the world, causing moderate to severe disease in about 15% of infected patients, COVID-19 is also found to have widespread effects throughout the body with a myriad of clinical manifestations including the endocrine system. This manuscript reviews what is known about the impact of COVID-19 on the pathophysiology and management of diabetes (both outpatient and inpatient) as well as pituitary, adrenal, thyroid, bone, and gonadal function. Findings in this area are evolving, and long-term effects of infection remain an active area of further research.
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Affiliation(s)
- Michelle D Lundholm
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Caroline Poku
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
| | - Nicholas Emanuele
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois.,Endocrinology Section, Medical Service, VA Hospital, Hines, Illinois
| | - Mary Ann Emanuele
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
| | - Norma Lopez
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
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25
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Umpierrez G, Rushakoff R, Seley JJ, Zhang JY, Shang T, Han J, Spanakis EK, Alexanian S, Drincic A, Kulasa K, Mendez CE, Tanton D, Wallia A, Zilbermint M, Klonoff DC. Hospital Diabetes Meeting 2020. J Diabetes Sci Technol 2020; 14:928-944. [PMID: 32783456 PMCID: PMC7477766 DOI: 10.1177/1932296820939626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with diabetes may experience adverse outcomes related to their glycemic control when hospitalized. Continuous glucose monitoring systems, insulin-dosing software, enhancements to the electronic health record, and other medical technologies are now available to improve hospital care. Because of these developments, new approaches are needed to incorporate evolving treatments into routine care. With the goal of educating healthcare professionals on the most recent practices and research for managing diabetes in the hospital, Diabetes Technology Society hosted the Virtual Hospital Diabetes Meeting on April 24-25, 2020. Because of the coronavirus disease 2019 (COVID-19) pandemic, the meeting was restructured to be held virtually during the national lockdown to ensure the safety of the participants and allow them to remain at their posts treating COVID-19 patients. The meeting focused on (1) inpatient management and perioperative care, (2) diabetic ketoacidosis and hyperglycemic hyperosmolar state, (3) computer-guided insulin dosing, (4) Coronavirus Disease 2019 and diabetes, (5) technology, (6) hypoglycemia, (7) data and cybersecurity, (8) special situations, (9) glucometrics and insulinometrics, and (10) quality and safety. This meeting report contains summaries of each of the ten sessions. A virtual poster session will be presented within two months of the meeting.
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Affiliation(s)
| | | | | | | | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | | | | | | | | | - Damon Tanton
- AdventHealth Diabetes Institute, Orlando, FL, USA
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
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26
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Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:165-173. [PMID: 32952507 PMCID: PMC7485658 DOI: 10.4103/sjmms.sjmms_478_19] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/20/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.
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Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
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Vidyasagar K, Chandrasekar B, Chhabra M, Bhansali A, Bansal D. Efficacy and Safety of Commonly Used Insulin Analogues in the Treatment of Diabetic Ketoacidosis: A Bayesian Indirect Treatment Comparison. Clin Ther 2020; 42:e115-e139. [PMID: 32798057 DOI: 10.1016/j.clinthera.2020.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Insulin analogues (IAs) are the mainstay for the management of diabetic ketoacidosis (DKA). However, the relative efficacy of newer IAs is uncertain. The aim of this study was to compare the relative efficacy and safety of IAs for the management of DKA using an indirect treatment comparison (ITC). METHODS PubMed, EMBASE, Scopus, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing short-, rapid-, and long-acting IAs in patients with DKA. The primary outcomes of interest were time taken to normalize DKA and time taken to normalize blood glucose levels. The secondary outcomes of interest were the amount of insulin needed to normalize DKA, the length of hospital stay, and the number of hypoglycemic events in the intervention and comparator groups. Bayesian ITC was performed by using the gemtc package in the R program. Continuous outcomes are reported as mean difference (MD), and binary outcomes are reported as odds ratios (ORs), with 95% credible intervals (CrIs). The Cochrane risk of bias tool was used to assess the risk of bias in the included RCTs. FINDINGS Ten RCTs randomizing 435 participants to treatment were included in this ITC. A total of 5 interventions (lispro, glargine with regular insulin [RI], glulisine, aspart, and regular insulin) were compared for both safety and efficacy outcomes in DKA. Glargine co-administered with regular insulin showed superiority for clinical outcomes compared with regular insulin: consuming less time (MD, -3.1 h; 95% CrI, -7.9 to 1.8), amount of insulin required (MD, -32 U; 95% CrI, 83.0 to 18.0), and the length of hospitalization (MD, -0.82 day; 95% CrI, -2.7 to 1.0) to normalize DKA. However, these results were not statistically significant. Insulin aspart had fewer reports of hypoglycemic events (OR, 1.7; 95% CrI, 0.34 to 9.3) than regular insulin. IMPLICATIONS Newer IAs were found to be equally effective and safe as regular insulin in the treatment of DKA. Thus, administering these IAs can be considered a safe and cost-effective alternative for DKA management in non-ICU settings. Cost-effective analysis of the newer IAs is needed because these agents are expensive compared with regular insulin.
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Affiliation(s)
- Kota Vidyasagar
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Boya Chandrasekar
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Manik Chhabra
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Dipika Bansal
- Division of Clinical Research, Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), SAS Nagar, Mohali, Punjab, India.
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28
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Castellanos L, Tuffaha M, Koren D, Levitsky LL. Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus. Paediatr Drugs 2020; 22:357-367. [PMID: 32449138 DOI: 10.1007/s40272-020-00397-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.
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Affiliation(s)
- Luz Castellanos
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Marwa Tuffaha
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Dorit Koren
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA.
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29
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Palermo NE, Sadhu AR, McDonnell ME. Diabetic Ketoacidosis in COVID-19: Unique Concerns and Considerations. J Clin Endocrinol Metab 2020; 105:5857202. [PMID: 32556147 PMCID: PMC7337869 DOI: 10.1210/clinem/dgaa360] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/05/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign. CASE DESCRIPTION This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach. CONCLUSIONS As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.
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Affiliation(s)
- Nadine E Palermo
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
| | - Archana R Sadhu
- Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Marie E McDonnell
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology, Diabetes and Hypertension, Boston, Massachusetts
- Correspondence and Reprint Requests: Marie E. McDonnell, MD, Director, Brigham and Women’s Hospital Diabetes Program, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA. E-mail:
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30
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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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31
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Bergmann KR, Abuzzahab MJ, Arms J, Cutler G, Vander Velden H, Simper T, Christensen E, Watson D, Kharbanda A. A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis. Pediatrics 2020; 145:peds.2019-1104. [PMID: 32054821 DOI: 10.1542/peds.2019-1104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness. METHODS We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes. RESULTS We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized. CONCLUSIONS Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.
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Affiliation(s)
| | - M Jennifer Abuzzahab
- Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St Paul, Minnesota; and
| | - Joe Arms
- Departments of Emergency Medicine
| | | | | | | | - Eric Christensen
- College of Continuing and Professional Studies, University of Minnesota, Minneapolis, Minnesota
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32
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Pasquel FJ, Tsegka K, Wang H, Cardona S, Galindo RJ, Fayfman M, Davis G, Vellanki P, Migdal A, Gujral U, Narayan KMV, Umpierrez GE. Clinical Outcomes in Patients With Isolated or Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: A Retrospective, Hospital-Based Cohort Study. Diabetes Care 2020; 43:349-357. [PMID: 31704689 PMCID: PMC6971788 DOI: 10.2337/dc19-1168] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises. RESEARCH DESIGN AND METHODS We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined 1) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); 2) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and 3) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality. RESULTS There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; P = 0.0019). In all groups, hypoglycemia (<40 mg/dL) during treatment was associated with a 4.8-fold increase in mortality (aOR 4.8; 95% CI 1.4, 16.8). Hypokalemia ≤3.5 mEq/L was frequent (55%). Severe hypokalemia (≤2.5 mEq/L) was associated with increased inpatient mortality (aOR 4.9; 95% CI 1.3, 18.8; P = 0.02). CONCLUSIONS Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.
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Affiliation(s)
| | - Katerina Tsegka
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Saumeth Cardona
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Georgia Davis
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Alexandra Migdal
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Unjali Gujral
- Rollins School of Public Health, Emory University, Atlanta, GA
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Reducing Diabetic Ketoacidosis Intensive Care Unit Admissions Through an Electronic Health Record-Driven, Standardized Care Pathway. J Healthc Qual 2020; 42:e66-e74. [DOI: 10.1097/jhq.0000000000000247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
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35
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Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract 2019; 155:107797. [PMID: 31344382 DOI: 10.1016/j.diabres.2019.107797] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
AIMS Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. METHODS Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines. RESULTS The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. CONCLUSIONS DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK; Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
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36
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care 2019; 9:92. [PMID: 31418093 PMCID: PMC6695455 DOI: 10.1186/s13613-019-0563-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/30/2019] [Indexed: 02/07/2023] Open
Abstract
Metabolic acidosis is a disorder frequently encountered in emergency medicine and intensive care medicine. As literature has been enriched with new data concerning the management of metabolic acidosis, the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Emergency Medicine Society (Société Française de Médecine d’Urgence [SFMU]) have developed formalized recommendations from experts using the GRADE methodology. The fields of diagnostic strategy, patient assessment, and referral and therapeutic management were addressed and 29 recommendations were made: 4 recommendations were strong (Grade 1), 10 were weak (Grade 2), and 15 were experts’ opinions. A strong agreement from voting participants was obtained for all recommendations. The application of Henderson–Hasselbalch and Stewart methods for the diagnosis of the metabolic acidosis mechanism is discussed and a diagnostic algorithm is proposed. The use of ketosis and venous and capillary lactatemia is also treated. The value of pH, lactatemia, and its kinetics for the referral of patients in pre-hospital and emergency departments is considered. Finally, the modalities of insulin therapy during diabetic ketoacidosis, the indications for sodium bicarbonate infusion and extra-renal purification as well as the modalities of mechanical ventilation during severe metabolic acidosis are addressed in therapeutic management.
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Affiliation(s)
- Boris Jung
- Département de Médecine Intensive et Réanimation, CHU Montpellier, 34000, Montpellier, France. .,INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.
| | - Mikaël Martinez
- Pôle Urgence, CH du Forez, 42605, Montbrison, France.,Réseau d'urgence Ligérien Ardèche Nord (REULIAN), Centre Hospitalier Le Corbusier, 42700, Firminy, France
| | - Yann-Erick Claessens
- Département de Médecine d'urgence, Centre Hospitalier Princesse-Grace, Avenue Pasteur, 98012, Monaco, France
| | - Michaël Darmon
- Unité de Médecine Intensive et Réanimation, Hôpital Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Avenue Claude-Vellefaux, 75010, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,France Inserm, ECSTRA Team, UMR 1153, Centre d'Epidémiologie et de Biostatistique, CRESS, Biostatistics and Clinical Epidemiology, Sorbonne-Paris-Cité, Paris, France
| | - Kada Klouche
- INSERM U-1046, CNRS U-9234 (PhyMedExp), Université de Montpellier, Montpellier, France.,Département de Médecine Intensive-Réanimation, CHU Lapeyronie, 371, Avenue Doyen-Gaston-Giraud, 34295, Montpellier, France
| | - Alexandre Lautrette
- Réanimation, Centre Jean-Perrin, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France.,LMGE, UMR CNRS 6023, Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Jacques Levraut
- Département de Médecine d'urgence, CHU de Nice, Hôpital Pasteur-II, 30, Avenue de la Voie Romaine, 06000, Nice, France.,UFR de Médecine, Université de Nice Côte d'Azur, Avenue de Vallombrose, 06000, Nice, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris-VI, Paris, France.,Inserm U1136, 75012, Paris, France
| | - Mathieu Oberlin
- Structure des Urgences, Centre Hospitalier de Cahors, 335, Rue Wilson, 46000, Cahors, France
| | - Nicolas Terzi
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire de Grenoble, Université de Grenoble, Grenoble, France.,Inserm, U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Damien Viglino
- Service des Urgences Adultes, CS 10217, CHU Grenoble-Alpes, 38043 Grenoble Cedex 09, Grenoble, France.,Inserm U1042, Laboratoire HP2 Hypoxie-Physiopathologies, Université Grenoble-Alpes, Grenoble, France
| | - Youri Yordanov
- Faculté de Médecine, Sorbonne Universités, 75013, Paris, France.,Inserm, U1153, Université Paris-Descartes, 75006, Paris, France.,Service des Urgences, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Pierre-Géraud Claret
- Pôle Anesthésie Réanimation Douleur Urgences, Centre Hospitalier Universitaire de Nîmes, 4, Rue du Professeur-Robert-Debré, 30029, Nîmes, France
| | - Naïke Bigé
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184, Rue du Faubourg-Saint-Antoine, 75571 Paris Cedex 12, Paris, France
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Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ 2019; 365:l1114. [PMID: 31142480 DOI: 10.1136/bmj.l1114] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.
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Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lorenson JL, Cusumano MC, Stewart AM, Buhnerkempe MG, Sanghavi D. Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 27:380-385. [PMID: 30847977 DOI: 10.1111/ijpp.12525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/16/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether hypoglycaemia incidence during management of adult diabetic ketoacidosis (DKA) differed following transition from a fixed-rate insulin protocol to a protocol using an empiric insulin rate reduction after normoglycaemia. METHODS We retrospectively reviewed charts from adult patients managed with a DKA order set before and after order set revision. In cohort 1 (n = 77), insulin rate was 0.1 unit/kg/h with no adjustments and dextrose was infused at 12.5 g/h after glucose reached 250 mg/dl. In cohort 2 (n = 78), insulin was reduced to 0.05 unit/kg/h concurrent with dextrose initiation at 12.5 g/h after glucose reached 200 mg/dl. The primary outcome was hypoglycaemia (glucose < 70 mg/dl) within 24 h of the first order for insulin. KEY FINDINGS The 24-h incidence of hypoglycaemia was 19.2% in cohort 2 versus 32.5% in cohort 1; the adjusted odds ratio was 0.46 (95% confidence interval (CI) [0.21, 0.98]; P = 0.047). The 24-h use of dextrose 50% in water (D50W) was also reduced in cohort 2. No differences were seen in anion gap or bicarbonate normalization, rebound hyperglycaemia or ICU length of stay. In most patients who became hypoglycaemic, the preceding glucose value was below 100 mg/dl. CONCLUSIONS The insulin rate-reduction protocol was associated with less hypoglycaemia and no obvious disadvantage. Robust intervention for low-normal glucose values could plausibly achieve low hypoglycaemia rates with either approach.
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Affiliation(s)
- Jessica L Lorenson
- HSHS St. John's Hospital, Springfield, IL, USA.,Southern Illinois University School of Pharmacy, Edwardsville, IL, USA
| | | | | | - Michael G Buhnerkempe
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
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Malerba E, Mazzarino M, Del Baldo F, Corradini S, Carotenuto G, Giunti M, Fracassi F. Use of lispro insulin for treatment of diabetic ketoacidosis in cats. J Feline Med Surg 2019; 21:115-123. [PMID: 29513157 PMCID: PMC10814606 DOI: 10.1177/1098612x18761696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the efficacy and safety of lispro insulin for the treatment of feline diabetic ketoacidosis (DKA). Times to resolution of hyperglycaemia, ketosis and acidosis were compared between cats treated with continuous rate infusion (CRI) of lispro insulin and cats treated with CRI of regular insulin. METHODS Client-owned cats with naturally occurring DKA, newly diagnosed with diabetes mellitus (DM) or already receiving treatment for DM, were included. Diagnosis of DKA involved the presence of at least two clinical signs consistent with DKA (eg, polyuria/polydipsia, anorexia, severe lethargy, vomiting and dehydration), blood glucose (BG) concentration >13.9 mmol/l (>250 mg/dl), blood beta hydroxybutyrate (BHB) concentration >2.5 mmol/l and venous pH <7.3 or bicarbonate <15 mEq/l. Cats were treated with a standard protocol of an intravenous (IV) CRI of regular insulin (group R) or lispro insulin (group L). The time to resolution of DKA was defined as the time interval from when the IV CRI of insulin began until marked hyperglycaemia (BG >13.9 mmol/l [>250 mg/dl]), ketosis (BHB concentration >1 mmol/l) and acidosis (venous pH <7.3 and/or bicarbonate <15 mEq/l) resolved. RESULTS Eighteen DKA cases (nine per group) were enrolled into the study. There were no significant differences in the median time to resolution of three variables (hyperglycaemia, ketosis and acidosis) between the two groups. Two cats in group R developed hypoglycaemia during the CRI of insulin. One cat in group L and three cats in group R developed hypophosphataemia, which required phosphate supplementation. CONCLUSIONS AND RELEVANCE IV CRI of lispro insulin has few side effects and appears to be as effective as IV CRI of regular insulin in the treatment of cats with DKA.
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Affiliation(s)
- Eleonora Malerba
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Michela Mazzarino
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Francesca Del Baldo
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Sara Corradini
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Gaia Carotenuto
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, University of Bologna, Ozzano dell’Emilia, Italy
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Gupta D, Prasad A, Siddiqui F, Sitaula S, Albert SG. Insulin infusion responses in diabetic ketoacidosis alone and with a mixed hypochloremic alkalosis. Diabetes Metab Syndr 2019; 13:216-221. [PMID: 30641700 DOI: 10.1016/j.dsx.2018.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/21/2018] [Indexed: 11/21/2022]
Abstract
AIMS Although diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA. MATERIALS AND METHODS A retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BECl) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L. RESULTS The initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BECl (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA. CONCLUSIONS Correction of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis.
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Affiliation(s)
- Deepashree Gupta
- Division of Endocrinology, University of California, Los Angeles, United States
| | - Anju Prasad
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Faisal Siddiqui
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Sujata Sitaula
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States
| | - Stewart G Albert
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, United States.
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Galm BP, Bagshaw SM, Senior PA. Acute Management of Diabetic Ketoacidosis in Adults at 3 Teaching Hospitals in Canada: A Multicentre, Retrospective Cohort Study. Can J Diabetes 2018; 43:309-315.e2. [PMID: 30579737 DOI: 10.1016/j.jcjd.2018.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/17/2018] [Accepted: 11/12/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Brandon P Galm
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Present affiliation: Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Peter A Senior
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine 2018; 61:267-274. [PMID: 29797212 DOI: 10.1007/s12020-018-1635-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the safety/efficacy of intermittent subcutaneous rapid-acting insulin aspart with the standard low-dose intravenous infusion protocol of regular insulin for treatment of pediatric diabetic-ketoacidosis. METHODS For a prospective randomized-controlled clinical trial on 50 children/adolescents with mild/moderate diabetic-ketoacidosis, the diagnostic criteria for ketoacidosis included: blood glucose level >250 mg/dl, ketonuria>++, venous pH <7.3 and/or bicarbonate <15 mEq/l. DATA COLLECTED age, sex, clinical/laboratory parameters including blood sugar, arterial blood gases, urine ketones, severity of diabetic-ketoacidosis, amount of insulin administered to correct acidosis, time to recover from diabetic-ketoacidosis, number of days of hospitalization, and complications. Patients were randomly assigned to intervention (subcutaneous) and control (intravenous) groups. Controls received 0.05-0.1 unit/kg/hour intravenous regular insulin infusion until resolution of diabetic-ketoacidosis and stayed in the intensive care unit. Interventions received 0.15 unit/kg subcutaneous insulin aspart every two hours and stayed in regular medical ward. RESULTS From 50 children (age 2-17 years), 56% (28) were females, and 48% (24) had established-type I diabetes. Intervention and control groups had similar baseline clinical/laboratory findings. Average age (years) was 8.6 ± 0.8 for intervention and 8.86 ± 0.7 for control group (p = 0.4) with 64% having moderate diabetic-ketoacidosis. The mean total-dose of insulin units needed for treatment of diabetic-ketoacidosis in intervention (subcutaneous insulin aspart) was lower than controls (intravenous regular insulin) (p < 0.001). No mortality/serious events happened. Three diabetic-ketoacidosis recurrences among interventions and one among controls occurred. CONCLUSIONS To manage mild/moderate diabetic-ketoacidosis in children/adolescents, subcutaneous rapid-acting insulin aspart is an alternative to intravenous infusion of regular insulin. Subcutaneous insulin treated moderate DKA with faster recovery/shorter hospital stay.
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Affiliation(s)
- Zahra Razavi
- Associate Professor, Pediatric Endocrinologist, Pediatrics Department, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran.
| | - Saba Maher
- Pediatric Senior Resident, Department of Pediatrics, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Javad Fredmal
- Associate Professor of Biostatistics, Hamedan University of Medical Sciences, Hamedan, Iran
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Guo C, Wang Q, Yang L, Wang H, Wang D, Tang X. Selective naked eye and turn-on fluorescence for detection of D-3-HB based on an erbium complex. J Photochem Photobiol A Chem 2018. [DOI: 10.1016/j.jphotochem.2017.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pipe-Martin HN, Fletcher JM, Gilor C, Mitchell MA. Pharmacodynamics and pharmacokinetics of insulin aspart assessed by use of the isoglycemic clamp method in healthy cats. Domest Anim Endocrinol 2018; 62:60-66. [PMID: 29101821 DOI: 10.1016/j.domaniend.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/07/2017] [Accepted: 09/07/2017] [Indexed: 11/21/2022]
Abstract
The objective of this study was to determine the pharmacodynamics (PD) and pharmacokinetics (PK) of insulin aspart in healthy cats following intramuscular (IM) and subcutaneous (SC) injection. Eight healthy, purpose-bred cats were used in a randomized, crossover study design. Each cat had 2 isoglycemic clamps performed, one after receiving 0.25 IU/kg of insulin aspart by IM injection and one after receiving the same dose by SC injection. The two isoglycemic clamps were performed on different days, at least 48 h apart. The blood glucose, plasma endogenous insulin, and plasma insulin aspart concentrations were measured and the glucose infusion rate (GIR) was recorded during the clamp. The GIR over time was used to create a time-action curve for each clamp which was used to describe the PD of insulin aspart. Data that are normally distributed are reported as mean ± SD, while data that are not normally distributed are reported as median (25-75 percentile). When compared to the PD data that have been reported for regular insulin in healthy cats, insulin aspart had a more rapid onset (IM: 10 min [10-21.25 min], SC: 12.5 min [10-18.75 min]) and shorter duration of action (IM: 182.5 ± 34.33 min, SC: 159.38 ± 41.87 min). The onset of action (P = 0.795), time to peak action (P = 0.499), duration of action (P = 0.301), and total metabolic effect (P = 0.603) did not differ with route of administration; however, SC administration did result in a higher maximum plasma insulin aspart concentration (IM: 1,265.17 pmol/L [999.69-1,433.89 pmol/L], SC: 3,278.19 pmol/L [2,485.29-4,132.01 pmol/L], P = 0.000) and larger area under the insulin aspart vs time curve (IM: 82,662 ± 30,565 pmol/L, SC: 135,060 ± 39,026 pmol/L, P = 0.010). Insulin aspart has a rapid onset of action and short duration of effect in healthy cats when administered by IM and SC injection. Although it cannot be assumed that the PD and PK of insulin aspart will be the same in cats with diabetic ketoacidosis (DKA), our data support further investigation into the use of SC insulin aspart as an alternative to regular insulin for the treatment of DKA in cats.
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Affiliation(s)
- H N Pipe-Martin
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA
| | - J M Fletcher
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA.
| | - C Gilor
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, California 95616, USA
| | - M A Mitchell
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana 70803, USA
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46
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Osborne AD. Care of Metabolic and Endocrine Conditions in the Observation Unit. Emerg Med Clin North Am 2017; 35:589-601. [DOI: 10.1016/j.emc.2017.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tran TTT, Pease A, Wood AJ, Zajac JD, Mårtensson J, Bellomo R, Ekinci EI. Review of Evidence for Adult Diabetic Ketoacidosis Management Protocols. Front Endocrinol (Lausanne) 2017; 8:106. [PMID: 28659865 PMCID: PMC5468371 DOI: 10.3389/fendo.2017.00106] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an endocrine emergency with associated risk of morbidity and mortality. Despite this, DKA management lacks strong evidence due to the absence of large randomised controlled trials (RCTs). OBJECTIVE To review existing studies investigating inpatient DKA management in adults, focusing on intravenous (IV) fluids; insulin administration; potassium, bicarbonate, and phosphate replacement; and DKA management protocols and impact of DKA resolution rates on outcomes. METHODS Ovid Medline searches were conducted with limits "all adult" and published between "1973 to current" applied. National consensus statements were also reviewed. Eligibility was determined by two reviewers' assessment of title, abstract, and availability. RESULTS A total of 85 eligible articles published between 1973 and 2016 were reviewed. The salient findings were (i) Crystalloids are favoured over colloids though evidence is lacking. The preferred crystalloid and hydration rates remain contentious. (ii) IV infusion of regular human insulin is preferred over the subcutaneous route or rapid acting insulin analogues. Administering an initial IV insulin bolus before low-dose insulin infusions obviates the need for supplemental insulin. Consensus-statements recommend fixed weight-based over "sliding scale" insulin infusions although evidence is weak. (iii) Potassium replacement is imperative although no trials compare replacement rates. (iv) Bicarbonate replacement offers no benefit in DKA with pH > 6.9. In severe metabolic acidosis with pH < 6.9, there is lack of both data and consensus regarding bicarbonate administration. (v) There is no evidence that phosphate replacement offers outcome benefits. Guidelines consider replacement appropriate in patients with cardiac dysfunction, anaemia, respiratory depression, or phosphate levels <0.32 mmol/L. (vi) Upon resolution of DKA, subcutaneous insulin is recommended with IV insulin infusions ceased with an overlap of 1-2 h. (vii) DKA resolution rates are often used as end points in studies, despite a lack of evidence that rapid resolution improves outcome. (viii) Implementation of DKA protocols lacks strong evidence for adherence but may lead to improved clinical outcomes. CONCLUSION There are major deficiencies in evidence for optimal management of DKA. Current practice is guided by weak evidence and consensus opinion. All aspects of DKA management require RCTs to affirm or redirect management and formulate consensus evidence-based practice to improve patient outcomes.
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Affiliation(s)
- Tara T. T. Tran
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anthony Pease
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Anna J. Wood
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Jeffrey D. Zajac
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Elif I. Ekinci
- Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
- Menzies School of Health Research, Darwin, NT, Australia
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48
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Cohen M, Leibovitz N, Shilo S, Zuckerman-Levin N, Shavit I, Shehadeh N. Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children. Pediatr Diabetes 2017; 18:290-296. [PMID: 27005007 DOI: 10.1111/pedi.12380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) treatment protocols vary, however low-dose intravenous administration of regular insulin is the standard care for replacing insulin in most centers. Few studies, the majority in adults, demonstrated subcutaneous injection of rapid-acting insulin every 1-2 hours to be a valid alternative. OBJECTIVE To evaluate the efficacy and safety of subcutaneous regular insulin administered every 4 hours in pediatric DKA in a clinical setting. METHODS A retrospective chart review was conducted. Charts of all children treated with subcutaneous regular insulin for DKA and pH ≥ 7.0, between 2007 and 2010, were reviewed. Seventy-six DKA episodes in 52 patients were included. Data regarding clinical characteristics, response to treatment, and the occurrence of complications were analyzed. DKA episodes in patients with new-onset diabetes and in those with established diabetes were compared. RESULTS Mean age was 11.6 ± 4.0 yr. Eighteen episodes occurred in children with new-onset diabetes. In all episodes, our protocol resulted in recovery from DKA. Median time to DKA resolution (pH > 7.30, HCO3 > 15) was 10.3 (5.5, 14.2) h. The median total insulin dose was 0.05 (0.04, 0.06) (unit/kg/h). During DKA treatment, hypoglycemia occurred in one episode and hypokalemia, mostly mild, was documented in 14. No cardiac arrhythmias, incidents of cerebral edema, or mortality occurred. CONCLUSION Subcutaneous regular insulin administered every 4 hours is an effective and safe alternative for the insulin treatment of DKA with pH > 7.0 in children. Such treatment has the potential to simplify insulin administration when compared to either intravenous regular insulin or q1-2 hour subcutaneous rapid insulin and reduce both patient inconvenience and admission costs.
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Affiliation(s)
- Michal Cohen
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Noa Leibovitz
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Smadar Shilo
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Nehama Zuckerman-Levin
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Itai Shavit
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Naim Shehadeh
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am 2017; 101:587-606. [PMID: 28372715 PMCID: PMC6535398 DOI: 10.1016/j.mcna.2016.12.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
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50
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Cardoso L, Vicente N, Rodrigues D, Gomes L, Carrilho F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism 2017; 68:43-54. [PMID: 28183452 DOI: 10.1016/j.metabol.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 01/22/2023]
Abstract
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
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Affiliation(s)
- Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Nuno Vicente
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Francisco Carrilho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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