Management of diabetic ketosis and ketoacidosis with intramuscular regular insulin in a low-resource family medicine setting

Glargine versus regular insulin protocol in feline diabetic ketoacidosis

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.

Clinical profiles, outcomes and risk factors among type 2 diabetic inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 6-year period

OBJECTIVE

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic emergencies (HEs) associated with diabetes mellitus. Individuals with HEs can present with combined features of DKA and HHS. The objective of this study is to assess the clinical characteristics, therapeutic outcomes, and associated predisposing factors of type 2 diabetic patients with isolated or combined HEs in China.

METHODS

We performed a retrospective analysis of 158 patients with type 2 diabetes (T2DM), complicated with DKA, HHS, or DKA combined with HHS (DKA-HHS) in Shanghai Tongji Hospital, China from 2010 to 2015. Admission clinical features, therapeutic approaches and treatment outcomes of those patients were extracted and analyzed.

RESULTS

Of the 158 patients with T2DM, 65 (41.1%) patients were DKA, 74 (46.8%) were HHS, and 19 (12.0%) were DKA-HHS. The most common precipitants were infections (111, 70.3%), newly diagnosed diabetes (28,17.7%) and non-compliance to medications (9, 5.7%). DKA patients were divided into mild, moderate and severe group, based on arterial blood gas. Spearman correlation analysis revealed that C-reaction protein (CRP) was positively correlated with severity of DKA, whereas age and fasting C peptide were inversely correlated with severity of DKA (P < 0.05). The mortality was 10.8% (17/158) in total and 21.6% (16/74) in the HHS group, 5.9% (1/17) in DKA-HHS. Spearman correlation analysis indicated that death in patients with HHS was positively correlated to effective plasma osmolality (EPO), renal function indicators and hepatic enzymes, while inversely associated with the continuous subcutaneous insulin infusion (CSII) therapy. Logistic regression analysis suggested that elevated blood urea nitrogen (BUN) on admission was an independent predisposing factor of mortality in HHS, while CSII might be a protective factor for patients with HHS. Furthermore, the receiver-operating characteristic (ROC) curve analysis indicated that BUN had the largest area under the ROC curves for predicting death in patients with HHS.

CONCLUSIONS

Our findings showed elevated CRP and decreased fasting C-peptide might serve as indicator for severe DKA. Elevated BUN might be an independent predictor of mortality in patients with HHS, whereas CSII might be a protective factor against death in HHS.

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

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.

Determinants of deranged thyroid function parameters in children admitted for management of diabetic ketoacidosis/diabetic ketosis

BACKGROUND

Euthyroid sick syndrome (ESS) frequently arises in children admitted with diabetic ketoacidosis/diabetic ketosis (DKA/DK). This study evaluates the interplay of various metabolic factors with occurrence of deranged thyroid function tests in children suffering from DKA/DK.

METHODS

98 DKA and 96 DK pediatric patients were selected from hospital records. Those on thyroxine replacement, with overt hypothyroidism, or with positive anti-thyroperoxidase (TPO) antibody were excluded. Tests for liver function, renal function, lipid profile, serum osmolarity, thyroid function, c-peptide levels, and glycosylated hemoglobin were done on all patients. Children were divided into euthyroid (n = 88) and ESS groups (n = 106).

RESULTS

The ESS group had a higher level of white blood cell count (WBC), plasma glucose (PG), beta-hydroxybutyric acid (β-HB), triglyceride (TG), anion gap (AG), glycosylated hemoglobin (HbA1c) and a lower level of HCO₃^-, prealbumin (PA), and albumin (ALB) compared with the euthyroid group (P < 0.05). Free T3 (FT3) levels were significantly correlated to β-HB, HCO₃^-, AG, PA, and HbA1c (r = - 0.642, 0.681, - 0.377, 0.581, - 0.309, respectively; P < 0.01). Free T4 (FT4) levels were significantly correlated to β-HB, HCO₃^-, and ALB levels (r = - 0.489, 0.338, 0.529, respectively; P < 0.01). TSH levels were significantly affected by HCO₃^- only (r = - 0.28; P < 0.01). HCO₃^- level was the most important factor deciding euthyroid or ESS on logistic regression analysis (OR = 0.844, P = 0.004, 95%CI = 0.751-0.948).

CONCLUSIONS

Lower levels of free thyroid hormones and occurrence of ESS were associated with a higher degree of acidosis in children with DKA/DK.

Correlation between the outcomes and severity of diabetic ketoacidosis: A retrospective pilot study

Introduction

Diabetic ketoacidosis (DKA) is a serious acute metabolic complication of diabetes mellitus (DM). It is classified into mild, moderate, and severe based on severity as per the American Diabetes Association (ADA) guidelines. There are limited data on the correlation between the severity of DKA and its outcomes using this classification system. The aim is to study the correlation between the outcomes and severity of DKA in a tertiary care center in India.

Methodology

In this retrospective pilot study, 1527 patients with DM were identified over a span of 3 years, of which 63 had a discharge diagnosis of DKA and 37 fulfilled the ADA criteria for DKA. Following inclusion details on clinical parameters and outcomes of patients with mild, moderate, and severe DKA were compared.

Results

Mild, moderate, and severe DKA accounted for 8%, 41%, and 51% of the patients, respectively. Intensive Care Unit (ICU) care was required in 6.7% and 47.4% of those with moderate and severe DKA, respectively. Invasive ventilation (IV) was required in 47% (9) of those with severe DKA only. The mortality rates were 13.3% and 26% among those with moderate and severe DKA. The mean expenditure was ₹29,000, ₹30,000, and ₹64,000 among those with mild, moderate, and severe DKA, respectively.

Conclusions

The ADA classification of severity of DKA correlates well with the duration of inhospital stay, costs of care, requirement of ICU care, need for IV or non-IV, and mortality. This suggests that this classification system could be a valuable tool in predicting outcomes.