DKA at diabetes diagnosis does not affect children’s long-term HbA1c
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Children with diabetic ketoacidosis at type 1 diabetes diagnosis did not have a significant difference in HbA1c at 5 years compared with those without DKA, according to study data.
“The presence of DKA at diabetes diagnosis is not associated with deteriorated long-term metabolic control in children using modern technologies like continuous subcutaneous insulin infusion,” Emilia Kowalczyk, MD, of the department of pediatric diabetology and pediatrics at the Pediatric Teaching Clinical Hospital of the Medical University of Warsaw, Poland, told Healio. “The early implementation of continuous subcutaneous insulin infusion into diabetes treatment may change the harmful effect of DKA and lead to a long-term HbA1c improvement.”
Researchers analyzed data from children diagnosed with type 1 diabetes with DKA at the onset of the disease at the Pediatric Teaching Clinical Hospital of the Medical University of Warsaw from 2010 to 2014. Participants were matched by age, sex and BMI with children diagnosed with type 1 diabetes and no presence of DKA. In both groups, 87% of participants used insulin pump therapy. All participants were followed for 5 years. Data were collected at diagnosis and every routine clinical visit for 5 years.
Among the 85 children with type 1 diabetes and DKA at diagnosis, 24% had severe DKA, 27% moderate DKA and 49% mild DKA. The DKA group had higher HbA1c at diabetes onset compared with the group without DKA (12.5% vs. 11.3%; P < .001). The DKA group had a sharp decline in HbA1c to 7.1% 1 year after diagnosis, with HbA1c remaining stable for the next 4 years. There was no significant difference in HbA1c between the DKA and non-DKA groups at any year during follow-up.
In a univariate linear regression model, use of an insulin pump was associated with a lower HbA1c at 5 years (beta = –1.46; 95% CI, –2.01 to –0.92; P < .001). DKA severity was not associated with a significant difference in fifth-year HbA1c. No differences were observed in metabolic control or daily insulin requirements between the two groups. There were also no differences in metabolic control by age or sex.
“Data concerning the influence of DKA on long-term metabolic control are incoherent, but most of them relate to a poor long-term prognosis if acidosis was present at diagnosis,” Kowalczyk said. “Surprisingly, we did not reveal this negative correlation. The insulin pump therapy was implemented at diabetes onset in our study, which was rare at that time. That is why we observed that early implementation of continuous subcutaneous insulin infusion might mitigate the negative consequences and all the burden of DKA at diabetes onset.”
Kowalczyk said future studies should analyze the effects of early continuous subcutaneous insulin infusion implementation versus late implementation on metabolic control in kids with type 1 diabetes and DKA.
For more information:
Emilia Kowalczyk, MD, can be reached at emilia.kowalczyk@uckwum.pl.
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In a single-center prospective case-control study of 85 Polish youths presenting in diabetic ketoacidosis at type 1 diabetes diagnosis, Kowalczyk and colleagues found that DKA at diagnosis was not associated with HbA1c in the 5-year follow-up period. These findings align with prior studies from the SWEET registry, which has a large European influence and captures a group with very good long-term glycemic control (Piccini B, et al. Pediatr Diabetes. 2019;doi.org/10.1111/pedi.12946). However, several large-scale studies of American youthz with higher HbA1c values have shown that DKA at type 1 diabetes diagnosis predicts inferior long-term glycemic control (Duca LM, et al. Pediatr Diabetes. 2019;doi:10.1111/pedi.12809. Duca LM, et al. Diabetes Care. 2017;doi:10.2337/dc17-0558). Given the association between DKA at diagnosis, health care insurance type, minority race and socioeconomic status in the U.S., these contradictory conclusions in two different populations may be explained by health care disparities and access to care, rather than to DKA at diagnosis.
In Poland there is free, universal health care, and 70% of the cost of insulin pump therapy is covered by the national health system. Eighty-seven percent of both cases and controls were treated with insulin pump therapy, and most started within 2 weeks of diagnosis. The authors reported an association between continuous subcutaneous insulin infusion use at baseline and lower HbA1c 5 years after diagnosis. These conclusions must be interpreted with caution. Insulin pump therapy is associated with better metabolic control, and throughout the five-year period, only one participant changed from pump therapy to multiple daily injection therapy. It may be pump therapy itself, rather than early initiation of pump therapy, that explains these findings.
It is especially important to consider that prior randomized controlled trials have not shown benefits to early initiation of insulin pump therapy. Given the homogeneity of the study population and high rates of insulin pump use with universal access to health care, further studies among larger, more diverse populations with varying degrees of glycemic control are needed to better assess the impact of early insulin pump initiation.
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