Increased Ketoacidosis in Cannabis Users With Type 1 Diabetes

Kristin Jenkins

November 05, 2018

Despite the legalization of marijuana in several US states, and most recently in Canada, scientists agree that many questions remain about the potential health consequences of cannabis use.

Now, findings from a survey of 450 adults with type 1 diabetes show that 30% reported using cannabis in the previous year and that this was associated with an almost doubling of the risk of diabetic ketoacidosis (DKA) compared with non-use (odds ratio [OR], 1.98; 8.4% vs 7.6%; P < .01).

And when adjusted for age, income, and method of insulin delivery, cannabis users had a hemoglobin A1c (HbA1c) level that was a mean 0.41% higher compared with non-users, the authors report in a research letter published online November 5 in JAMA Internal Medicine.

However, there was no difference in severe hypoglycemia (20.3% vs 15.6%; P = .17) between cannabis users and non-users with type 1 diabetes, say Halis K. Akturk, MD, of the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, and colleagues.

"Cannabinoids alter gut motility and cause hyperemesis which may play a role in increased risk for DKA in type 1 diabetes," the authors write.

Colorado Study, Where Medical and Recreational Cannabis Use Are Legal

"Cannabis use is increasing with the shifts in legality and public perceptions in the United States," the investigators point out. "Studies have reported improvement in insulin sensitivity and pancreatic beta-cell function with cannabis use, generating widespread media attention suggesting cannabis as a potential therapeutic agent for treatment of type 2 diabetes."

But in 2016 (Am J Med. 2016;129:e139-140), the authors reported two cases of recurrent DKA associated with chronic cannabis use in patients with type 1 diabetes. It was on the basis of this that they decided to investigate the characteristics of cannabis use among adults with type 1 diabetes and the association of cannabis use with DKA.

The current study population was made up of 450 adults with type 1 diabetes attending a diabetes clinic at the Barbara Davis Center for Diabetes between June 2017 and January 2018. The diabetes center is the largest in Colorado, where medical and recreational use of cannabis is legal, Akturk and colleagues note.

Adults with type 1 diabetes were invited to complete an in-person questionnaire on their cannabis use. The survey was also used to collect data on patient demographics, and history of diabetes and complications, including severe hypoglycemia requiring hospitalization.

Study participants also underwent point-of-care HbA1c measurement. Hazardous cannabis use was defined as a score between ≥ 8 and < 12 on the revised Cannabis Use Disorder Identification Test-Revised (Drug Alcohol Depend. 2010;110:137-143). Possible cannabis use disorder was defined as a score ≥ 12.

Sensitivity analyses were performed in cannabis users matched with non-users for a number of variables, including age, sex, ethnicity, tobacco, and alcohol use.

Out of 631 eligible patients, 450 (71.3%) responded to the survey. Characteristics such as age and diabetes duration were similar between responders to the survey and nonresponders.

Among those who responded, cannabis users were younger (31 vs 39 years), had less education, and had a lower income than non-users. Cannabis users also had had diabetes for a shorter period of time (16 vs 21 years).

The primary study outcome was DKA hospitalization during the preceding 12 months. All self-reported DKA hospitalizations were confirmed by medical record review.

Many participants reported using both insulin pump and continuous glucose monitoring.

Cannabis Use Disorder in Almost a Fifth of Participants

Of the 134 adults with type 1 diabetes who reported using cannabis in the last 12 months, 75% said they did so for recreational purposes, 18% for diabetes-related reasons, and 25% for nondiabetes-related reasons.

Of adults with type 1 diabetes who reported using cannabis, 53% had been doing so for more than 3 years and 40% reported using it more than four times a week.

The study also showed that 24% of those with type 1 diabetes who reported using cannabis had a use score high enough to be considered hazardous, and 18% had a score that indicated a possible cannabis use disorder.

The authors point out, however, that the single-center study is limited by the small sample size, self-reported diabetes outcomes, and possibly by unmeasured confounders, such as access to healthcare.

"Further research is needed to confirm these findings and understand the effects and adverse consequences of cannabis use in patients with type 1 diabetes," they conclude.

Senior author Shah has reported receiving research support through the University of Colorado from Sanofi US, Dexcom, Eyenuk, and T1D Exchange clinic registry, and consulting fees through the University of Colorado from Sanofi US and Dexcom, all outside the submitted work.

JAMA Intern Med. Published online November 5, 2018. Abstract

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