Prolonged Ketosis in Hyperglycemic Emergencies Seen With COVID-19

By Reuters Staff

July 10, 2020

NEW YORK (Reuters Health) - COVID-19 may lead to hyperglycemic emergencies and protracted ketonemia in patients with diabetes, according to a case series from the UK.

Diabetes has emerged as a major risk factor for severe disease and death in patients with COVID-19. A recent study from China found that ketosis and ketoacidosis were common in hospitalized diabetes patients with COVID-19. However, data on the characteristics of hyperglycemic emergencies - diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) - occurring in the context of COVID-19 are lacking.

In an article online in Lancet Diabetes & Endocrinology, Dr. Efthimia Karra from Royal Free Hospital in London and colleagues describe 35 COVID-19 patients admitted to hospitals in north London with hyperglycemic emergencies, including 11 with DKA, 13 with mixed DKA/HHS, nine with hyperglycemic ketosis and two with HHS.

Their median age was 60 years, 28 (80%) had type 2 diabetes, 5 (14%) had type 1 diabetes and 2 (6%) were "new presentation" of diabetes. Forty percent were African American, 20% Caucasian, 17% mixed ethnic origin, and 14% Asian (6% Chinese and 9% Indian origin).

There was a "striking" type 2 disease overrepresentation in those presenting with DKA (82%), "suggesting acute insulinopenia in patients with COVID-19 and with type 2 diabetes, which persisted up until the time of discharge in 30% of patients previously not insulin-treated," the clinicians report.

In addition, they say the patients developed "protracted ketonemia and ketoacidosis," with median time to ketone resolution in DKA of roughly 35 hours (range, 24 to 60 hours). In non-COVID-19 DKA cases, in contrast, the median duration of ketoacidosis is about 12 hours, they note.

"Emerging reports suggest substantial insulin resistance and possibly relative insulinopenia in severe COVID-19 disproportionate to that seen in critical illness caused by other conditions, which might have contributed to the metabolic decompensation," the clinicians say.

"In line with these observations, 35% of patients in our study required an increase of the fixed dose insulin infusion above the recommended insulin dose for DKA of 0.1 units/kg per h. The slower fluid administration in the context of co-existing respiratory complications might also explain at least in part the protracted ketonemia," they note.

Dr. Karra and colleagues say larger observational studies are needed to clarify the diabetogenic effects of COVID-19, as well as the impact of medication adherence, blood sugar control before and during hospitalization and ethnicity on the development of COVID-19.

Dr. Karra did not respond to a request for comment by press time.

SOURCE: Lancet Diabetes & Endocrinology, online July 1, 2020.