Close follow-up, education critical for preventing recurrence of hyperglycemic crises
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Key takeaways:
- Adults with diabetes hospitalized with DKA recurrence have a higher risk for mortality.
- Providers should closely monitor patients with DKA for complications and provide education at discharge.
NEW ORLEANS — A consensus statement on managing diabetic ketoacidosis and hyperosmolar hyperglycemic state for adults with diabetes focuses on preventing recurrence and providing people with the tools to maintain glycemic control.
During a plenary presentation at the AACE annual meeting, Guillermo E. Umpierrez, MD, professor of medicine in the division of endocrinology at Emory University School of Medicine and director of the diabetes and endocrinology section at Grady Memorial Hospital in Atlanta, discussed a new consensus guideline on the management of hyperglycemic crises for adults with diabetes. The statement was drafted by the American Diabetes Association, European Association for the Study of Diabetes (EASD), AACE, the Joint British Societies for Inpatient Care, and the Diabetes Technology Society. Originally presented at the EASD 2023 annual meeting and scheduled for publication later this year in Diabetes Care and Diabetologia, the statement is the first update on the management of hyperglycemic crises since the ADA last published a consensus statement on the topic in 2009. Since that update, Umpierrez said there has been a lot of new studies published on DKA and hyperosmolar hyperglycemic state (HHS), all while hospitalizations for the two conditions continue to rise.
“Both in the U.S. and in Europe, there has been a tremendous increase, a significant increase in the number of admissions for DKA, both in type 1 and type 2 diabetes,” Umpierrez said. “It should be a preventable disease, but unfortunately, the numbers continue to increase.”
DKA and HHS share some features in common, but also differ in a few ways. Umpierrez said DKA develops over hours to days and the patient is usually alert when arriving at the hospital. DKA is also associated with nausea, vomiting and abdominal pain. HHS develops over several days and commonly includes changes in cognitive state.
DKA and HHS may both occur at the same time for some people. A study published in Diabetes Care in 2019 found 27% of adults admitted to one of two Atlanta hospitals with a hyperglycemic crisis presented with symptoms of both DKA and HHS. Umpierrez cautioned, however, that no population-level data on mixed DKA and HHS exist.
Another big difference between the conditions is the mortality rate. For DKA, mortality rates have declined to less than 1%, according to Umpierrez, while HHS has a fivefold to 10-fold higher mortality rate than DKA.
DKA mortality rates have declined over time, but the risks are greater for adults with recurrent DKA. A study published in Diabetologia in 2016 found adults with two to five DKA hospital admissions had a more than three times higher risk for mortality than those with a single admission, and adults with more than five DKA admissions had a more than six times higher risk for death than adults with one DKA admission. Umpierrez put a large focus on preventing recurrent DKA during his presentation.
“If you see a patient with recurrent DKA, please pay attention,” Umpierrez said. “Look for psychological reasons and see how you can help them, because mortality is quite high.”
Diagnosis, management changes
There are several changes with diagnosing and managing hyperglycemic crises in the new guidance. The cutoff for hyperglycemia has been lowered from 250 mg/dL or higher in the 2009 statement to 200 mg/dL or higher in the new guideline. The new guidance also strongly recommends assessing ketones with a point-of-care or serum beta-hydroxybutyrate measurement. Elevated ketones are defined as having a beta-hydroxybutyrate level of more than 3 mmol/L. Metabolic acidosis is defined as a pH level of less than 7.3 or bicarbonate concentration of less than 18 mmol/L. The bicarbonate level cutoff has been raised from 15 mmol/L in the 2009 guideline.
The new guideline also removed anion gap from the definition of DKA, though Umpierrez said anion gap can be used when ketone testing is not available.
The biggest change with DKA and HHS management is the removal of bicarbonates as a therapy option during hospitalization. The new guideline includes treatment with IV fluids, insulin and potassium.
When choosing IV fluids, Umpierrez said availability, costs and resources should determine the fluid choice, though most clinical guidelines recommend isotonic saline. For insulin therapy, the statement recommends subcutaneous insulin for people with mild DKA and IV insulin with moderate or severe DKA or HHS. Rapid-acting subcutaneous insulin analogs are not recommended for people with severe and complicated DKA or HHS.
Potassium replacement should be administered when serum levels drop to less than 5 mmol/L. Umpierrez said potassium levels should be maintained between 4 mmol/L and 5 mmol/L to prevent hypokalemia.
Umpierrez said the criteria for DKA resolution is a venous pH level of 7.3 or higher or a bicarbonate of 18 mmol/L or greater, and a ketone level of less than 0.6 mmol/L. For resolution of HHS, serum osmolality needs to decline to less than 300 mOsm/kg, glucose should be less than 250 mg/dL, urine output should increase to more than 0.5 mL/kg per hour and cognitive status should improve.
When a person with DKA or HHS is ready to transition away from IV insulin, subcutaneous insulin needs to be started for 1 to 2 hours before IV insulin is stopped. Umpierrez emphasized that 24-hour insulin coverage is needed. For people with type 1 diabetes, noninsulin agents are not recommended and SGLT2 inhibitors should not be used.
“Everybody with type 1 and type 2 diabetes presenting with DKA or HHS needs to be treated with insulin,” Umpierrez said.
There are currently no studies on transitioning to ultra long-acting insulin, according to Umpierrez. A long-acting basal insulin analog may be used as a backup replacement therapy, as limited pilot studies show it may reduce rates of rebound hyperglycemia.
It is important for providers to be aware of possible complications during care transitions, according to Umpierrez. The guidance includes mitigation strategies for treating hypoglycemia, hypokalemia, thrombosis, cerebral edema, osmotic demyelination syndrome and acute kidney injury.
Preventing recurrence
After a person with DKA or HHS is discharged, close follow-up is essential, Umpierrez said. A study published in Endocrine Practice in 2019 found 12.3% of adults hospitalized with DKA in the U.S. were readmitted within 30 days of discharge.
After discharge, it is crucial for providers to prevent the recurrence of DKA or HHS, according to Umpierrez. Providers should offer appropriate education to people before discharge that focuses on glycemic control, problem-solving skills, sick day rules, injection techniques, insulin doses and ketone testing.
Umpierrez said providers should also consider prescribing continuous glucose monitoring upon discharge.
“Everybody who is admitted with DKA — most of them have type 1 diabetes or are insulin-dependent — would benefit from the use of technology, because that may prevent readmissions,” Umpierrez said.
Providers must also prescribe an adequate supply of insulin and diabetes equipment when people are discharged, Umpierrez said.
References:
Gibb FW, et al. Diabetologia. 2016;doi:10.1007/s00125-016-4034-0.
Hurtado CR, et al. Endocr Pract. 2019;doi:10.4158/EP-2018-0457.
Pasquel FJ, et al. Diabetes Care. 2019;doi:10.2337/dc19-1168.
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Umpierrez GE. Management of hyperglycemic crises in adults with diabetes. Presented at: American Association of Clinical Endocrinology Annual Scientific and Clinical Conference; May 9-11, 2024; New Orleans.
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