Diabetic Ketoacidosis Is Preventable With Proper Treatment

Sara Hunt, MSN, RN, PHN, FNP-C, is a licensed and board-certified family nurse practitioner, a public health nurse, an adjunct assistant professor of health policy, and a doctor of nursing practice student at the University of California, San Francisco. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC.

Diabetes is 1 of the top 3 common chronic conditions in the United States that leads to death and disability¹and is the 7^th-leading cause of death.²

Cancer, diabetes, and heart disease account for a large portion of the $3.3 trillion annual US health care expenditures.³In fact, 90% of these expenditures are due to chronic conditions.³About 23 million people in the United States have diabetes, 7 million have undiagnosed diabetes,⁴and 83 million have prediabetes.³Untreated diabetes can become life-threatening, and the disease is the No. 1 cause of adult blindness, kidney failure, and lower-limb amputation.²Of these life-threatening complications, diabetic ketoacidosis (DKA) is the leading cause of the death in type 1 diabetes (T1D) and is preventable with proper treatment.

DKA is characterized by hyperglycemia (>250 mg/dL), increased ketones, and metabolic acidosis.⁴DKA develops when diabetes, usually T1D, is uncontrolled and the body does not have enough insulin to allow glucose into cells and be used for energy.⁵Once this happens, glucose continues to accumulate in the blood and the liver starts to breakdown fat into ketones.⁵In the rare circumstance, it is possible to have DKA with a blood sugar of less than 200 mg/dL.⁶This is called euglycemic DKA, and it is hypothesized that it could be caused by chronic liver disease, decreased caloric intake, glycogen storage disorders, heavy alcohol consumption, pregnancy, recent insulin use, or recent use of sodium glucose cotransporter 2 inhibitors.⁶

DKA is a rare, life threatening condition that can occur with T1D and occasionally type 2 diabetes. DKA is often the first presenting symptom of T1D in children and it is also more common in younger people with T1D, especially those younger than 19.^7,8It is estimated that DKA at initial presentation is between 13% and 80%, varying greatly by region.⁷For example, the frequency of DKA at diagnosis is as high as 67% in Romania and 80% in the United Arab Emirates and as low as 13% to 14% in Sweden.⁷Among people who have T1D, the rate of DKA can be as high as 100% in countries such as Algeria, Morocco, and Tunisia.⁸Some research has found that patients who experience DKA at initial presentation may have been experiencing DKA symptoms for more than 2 weeks.⁷The symptoms may go unrecognized not only by caregivers and patients but by clinicians.⁷Greater awareness of this condition is needed to prevent this disease from progressing into a life-threatening state.

Although T1D only represents about 5% of diabetes, it is 1 of the most common chronic pediatric conditions,⁷and the number of hospitalizations in the US from DKA been increasing.⁴Between 2000 and 2009, the number of hospitalizations from DKA decreased, but between 2009 and 2014 the rate of hospitalizations increased by 54.9%,⁴and people younger than 45 were 27 times more likely to be hospitalized than those older than 65.⁴Interestingly, even though the rate of hospitalization has been increasing in the United States, which could be to the result of a multitude of factors, the in-hospital mortality rate in the United States has been decreasing.⁴Those who survive an episode of DKA may suffer from persistent short-term memory loss and even a decrease in their intelligence quotient.⁷

To prevent the potentially devastating consequences of DKA, it is imperative for clinicians to recognize the signs and symptoms of DKA and T1D and educate caregivers and patients.

Risks for DKA at the time of diabetes diagnosis⁷include being younger than 5 years of age, with some research showing that children younger than 2 years have 3 times the risk of presenting with DKA than children older than 2 years; delayed diagnosis or misdiagnosis; lacking private health insurance; lower socioeconomic status; or residing in areas with a low occurrence of T1D.

Risk factors for DKA in children with established T1D⁷include being younger than 13 years or female; lack of private health insurance, low socioeconomic background; poor family relations; poor glycemic control; psychiatric conditions; and taking higher insulin dosages.

Presentation symptoms⁵include abdominal pain; altered level of consciousness; breath that smells like fruit, nail polish, or nail polish remover; coma; decreased appetite or reflexes; difficulty breathing; disorientation; hypothermia; ill appearance, as DKA may coincide with another illness, so watch for chills, cough, fever, or malaise; kussmaul breathing and/or tachypnea; lethargy; nausea; polyuria; rapid weight loss; signs of dehydration, such as decreased skin turgor, dry mucous membranes or skin, hypotension, and tachycardia; vomiting; weakness; and xerostomia.

Prevention of DKA

Counsel patients about the following tips:

• Diet.Patients should coordinate with all members of their care team regarding their diet and treatment plan. The care team should ideally include a registered dietician (RD) who can help manage this complex chronic condition. An RD can help improve glycemic control and delay the onset of diabetes complications.⁹Dyslipidemia, hypertension, and nephropathy are associated with hyperglycemia and obesity.⁹Uncontrolled diabetes increases the risk of dental, heart, and kidney disease; foot problems; nerve damage; retinopathy; and stroke.⁹Hypoglycemic episodes can lead to convulsions, death, seizures, or unconsciousness.⁹

• Early recognition of the signs and symptoms of hyperglycemia before it evolves into DKA.

• Exercise.About 60% of those with T1D are obese or overweight and have dyslipidemia, 40% have hypertension, and most are physical underactive.¹⁰Patients should discuss how to start an exercise routine with their care team to maintain safe blood glucose levels.

• Proper insulin use.Managing T1D is complex and requires careful titration of insulin dosages, which can vary by comorbidities, development, illness, periods of growth, physical activity, and various other factors.⁹Patients should also discuss with their care team how often and when to check blood sugars.

• Sufficient dietary fiber intake.Fiber can help patients manage diabetes by delaying or reducing glucose absorption, improving low-density lipoprotein cholesterol and minimizing post-prandial glycemic spikes.⁹

References

1. CDC. About chronic diseases. cdc.gov/chronicdisease/about/index.htm. Updated July 30, 2019. Accessed August 29, 2019.
2. CDC. Diabetes. cdc.gov/diabetes/basics/diabetes.html. Updated August 6, 2019. Accessed August 29, 2019.
3. CDC. Health and economic costs of chronic disease. cdc.gov/chronicdisease/about/costs/index.htm. Updated February 11, 2019. Accessed August 29, 2019.

4. Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in diabetic ketoacidosis hospitalizations and in-hospital mortality - United States, 2000—2014.MMWR Morb Mortal Wkly Rep.2018;67(12):362-365. doi: 10.15585/mmwr.mm6712a3.

5. Hamdy O. Diabetic ketoacidosis (DKA). Medscape. May 31, 2019. emedicine.medscape.com/article/118361-overview. Accessed August 29, 2019.

6. Modi A, Agrawal A, Morgan F. Euglycemic Diabetic Ketoacidosis: A Review.Curr Diabetes Rev. 2017;13(3):315-321. doi:10.2174/1573399812666160421121307

7. Jefferies C, Nakhla M, Derraik JG, Gunn AJ, Daneman D, Cutfield WS. Preventing diabetic ketoacidosis.Pediatr Clin North Am. 2015;62(4):857-871. doi:10.1016/j.pcl.2015.04.002

8. Zayed H. Epidemiology of diabetic ketoacidosis in Arab patients with type 1 diabetes: a systematic review.Int J Clin Pract. 2016;70(3):186-195. doi:10.1111/ijcp.12777.

9. Steinke TJ, O'Callahan EL, York JL. Role of a registered dietitian in pediatric type 1 and type 2 diabetes.Transl Pediatr. 2017;6(4):365—372. doi: 10.21037/tp.2017.09.05. doi:10.21037/tp.2017.09.05

10. Riddell M, Gallen IW, Smart CE, et al. Exercise management in type 1 diabetes: a consensus statement.Lancet Diabetes Endocrinol. 2017;5(5):377-390. doi:10.1016/s2213-8587(17)30014-1