COVID-19 Complicates Diabetic Ketoacidosis in Hospital

Miriam E. Tucker

March 10, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The clinical course and prognosis of individuals hospitalized with diabetic ketoacidosis (DKA) are considerably worse among those who have COVID-19, new data show.

In-hospital death was sixfold greater among patients with DKA who had COVID-19 compared with those who did not, and acute kidney injury was three times more common. "These findings are worrisome and warrant further investigation," write Francisco J. Pasquel, MD, and associates in their paper published online March 10 in JAMA Network Open.

Prior to the pandemic, hospitalizations for DKA had been rising but the case-fatality rate for such affected patients had been declining.

"However, with the advent of COVID-19, a suspected increase in the frequency and severity of DKA has been hypothesized because of the potential diabetogenic effect of severe SARS-CoV-2," Pasquel, of the Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, and colleagues write.

The study used the Glytec national database and included a total of 5029 patients with DKA treated at 175 hospitals in 17 US states from February 1 to September 15, 2020. Of those patients, 4% (210) had COVID-19 and 96% (4819) did not. All had been treated with the same computerized continuous insulin infusion algorithm for 4 or more hours.

The DKA patients with COVID-19 were significantly older (56 years vs 47 years; P < .001) and had a higher body mass index (31 kg/m2 vs 28 kg/m2; P < .001) than did those without COVID-19. But metabolic parameters including hemoglobin A1c, glucose, potassium, sodium bicarbonate, and anion gap on admission were similar between those with and without COVID-19.

In-hospital death occurred in 30% with COVID-19 compared to just 5% of those without COVID-19 (P < .001). Acute kidney injury occurred in 30% with COVID-19 vs 10% without (P < .001).

Mortality increased with age among both those with and without COIVD-19. Among those older than 65 years, 45% with COVID-19 died compared with 13% without COVID-19. But even in those younger than 45 years, mortality rates were 19% with COVID-19 vs 2% without.

The patients with COVID-19 had higher insulin requirements (5.0 vs 3.6 units/hour; P < .001), a longer duration of insulin treatment (34 vs 23 hours; P < .001), and a longer time to DKA resolution with blood glucose < 180 mg/dL (9.9 vs 7.1 hours; P < .001).

The higher insulin requirements among those with COVID-19 suggest that obesity and a more severe stress state could be contributing to the higher mortality rate, Pasquel and colleagues hypothesize.

Hypokalemia and hyperosmolality were common and the proportion with hypoglycemia was similar in both groups.

Pasquel reported research support from Dexcom and Merck and personal fees from Boehringer Ingelheim, AstraZeneca, Eli Lilly and Co, and Merck outside the submitted work. He is partially supported by the National Institutes of Health. Four co-authors are Glytec employees.

JAMA Netw Open. 2021;4(3):e211091. Full text

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