Cannabis Use Doubles Risk for Ketoacidosis in Type 1 Diabetes

Miriam E. Tucker

October 25, 2019

Cannabis use appears to be associated with an increased risk for diabetic ketoacidosis (DKA) among people with type 1 diabetes, new research finds.

The results, from the T1D Exchange clinic registry (T1DX), were published online October 18 in Diabetes Care by Gregory L. Kinney, MPH, PhD, from the University of Colorado Anschutz Medical Campus, Aurora, and colleagues.

Of 932 adults with type 1 diabetes, the risk for DKA among the 61 moderate cannabis users was more than twofold greater than in nonusers.

This result is similar to one in a study reported a year ago, which found that 30% of adults with type 1 diabetes surveyed admitted to using cannabis and that they, too, had a doubling of risk for DKA.

"Cannabis is a known addictive substance, and this potentially problematic aspect of cannabis use should be assessed in patients with type 1 diabetes. Providers should discuss with their patients who use cannabis the possibility of altered glycemic control, CHS [cannabis hyperemesis syndrome], and DKA," Kinney and colleagues write.

Cannabis is now legal for medical or recreational use in more than half of U.S. states, and although cannabis use among people with type 1 diabetes is not well described in the literature, evidence from adolescents suggests that it does not differ from that in the general population, the authors note.

Large Study Finds DKA Risk With Cannabis Use

To try to better categorize cannabis use in type 1 diabetes, the researchers recruited the 932 participants, who were among 1000 from T1Dx invited to complete the Alcohol, Smoking and Substance Involvement Screening Test questionnaire. This instrument generates a total substance score for cannabis (TSC) of 0 to 33, using a point system derived from six questions about use.

The scores are used to classify participants by recommended intervention, with 0 to 3 being low risk/no intervention, 4 to 26 as moderate risk/brief intervention, and greater than 26 as high risk/intensive intervention.

The authors compared the "no intervention" group with those having higher exposure scores.

No participants fell into the highest use category for cannabis, but 61 had moderate use (TSC > 4).

The latter group was younger (31 vs 38 years), was more often male (54% vs 38%), had less academic education, had a younger age at diabetes diagnosis (13 vs 16 years), had a higher A1c (8.4% vs 7.7%), were less likely to be using continuous glucose monitoring (21% vs 34%), and performed less self-monitoring of blood glucose.

Race, insulin pump use, frequency of severe hypoglycemia necessitating hospitalization, and alcohol use did not differ between the two


After adjustment for sex, age at study visit, and A1c, DKA was significantly associated with a TSC greater than 4, with an odds ratio of 2.5. Further adjustment for the legal status of cannabis in the state of the participant's residence didn't alter the association.

More Research to Understand Link Between Cannabis Use and DKA

The researchers say that cannabis delays gastric emptying, and this is thought to play a role in disruption of blood glucose control.

"Cannabis-induced alterations to gut motility, food absorption, and postprandial glycemic timing may be unexpected and inconsistent for the typical cannabis user with type 1 diabetes," they write.

Moreover, they add that cannabis-induced increased appetite can contribute to elevated glucose levels, and the cognitive effects of the drug can alter perception of hypoglycemia.

Studies have also suggested a link between long-term cannabis use and CHS, "which is characterized by cyclic episodes of nausea and vomiting and may result in an increased risk for DKA."

However, CHS, which is observed primarily in heavy cannabis users, was not observed in the T1DX participants, "limiting our ability to assess CHS and DKA."

"More research is needed to understand the mechanistic link between cannabis use and DKA," they conclude.

The T1D Exchange is funded by the Helmsley Charitable Trust. Kinney was supported by faculty development funds through the Department of Epidemiology at Colorado School of Public Health.

Diabetes Care. Published online October 18, 2019. Abstract

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