COVID-19 may be linked to diabetic ketoacidosis and hyperglycaemic emergencies in diabetic patients

July 17, 2020 0 By FM

COVID-19 is associated with hyperglycaemic emergencies with an overrepresentation of type 2 diabetes in patients presenting with diabetic ketoacidosis (DKA) and long-lasting ketosis,  reveals a retrospective case series study published in the journal Lancet Diabetes & Endocrinology.

Uncontrolled diabetes is a major contributor to disease severity and mortality in patients with COVID-19. Patients with type 1 diabetes are at 3·5-times increased risk of death during hospital admission and those with type 2 diabetes are at 2·03-times risk for death. Hyperosmolar hyperglycaemic state (HHS) and DKA are hyperglycaemia emergencies associated with substantial mortality, noted the authors.

The study analysed a series of hyperglycaemic emergencies hospitalised during the COVID-19 outbreak in three different hospitals in north London, UK, between March 1–30. 35 patients with a median age of 60 years with COVID-19, presented with DKA (31·4%), mixed DKA and HHS (37·1%), HHS (5·7%), or hyperglycaemic ketosis (25·7%) were evaluated.

Type 2 diabetes was prevalent in 28 (80%), whereas 2 (5·7%) of the 35 patients were new presentation of diabetes. The previous history of DKA was found in 5 patients with type 1 disease. Median overall HbA1c was 111 mmol/mol (IFCC; diabetes diagnostic cut-off ≥48 mmol/mol).

With regards to ethnicity, 40% of patients were African, 20% Caucasian, 17·1% of mixed ethnic origin, and 14·3% Asian (5·7% of Chinese and 8·6% of 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. The condition persisted until the time of discharge in 30% of patients who were not treated with insulin previously.

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.

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.

35% of patients in the study required an increase of the fixed-dose insulin infusion above the recommended insulin dose for DKA of 0.1 units/kg per hour. The slower fluid administration in the context of co-existing respiratory complications might also explain at least in part the protracted ketonemia, noted the authors.

“Further large-scale observational studies are needed to elucidate the diabetogenic effects of COVID-19, and the impact of factors such as medication adherence, glycaemic control pre- and during hospitalisation and ethnicity on the development of COVID-19,” wrote the authors.

The study, “Protracted ketonaemia in hyperglycaemic emergencies in COVID-19: a retrospective case series,” is available online in the Lancet.