Recommendations for Management of Diabetic Ketoacidosis in COVID-19

A clinical perspective published in The Journal of Clinical Endocrinology & Metabolism detailed the recommended approach to manage diabetic ketoacidosis (DKA) in patients with diabetes during the coronavirus disease 2019 (COVID-19) pandemic.

Insulin deficiency, which can be absolute or relative, is the key element in the pathogenesis of DKA; the most common causes of DKA are missed insulin doses and underlying severe illness. As DKA is an inflammatory state, high levels of inflammatory markers, such as interleukin-6 (IL-6), may have an important role in disease process.

The risk for DKA is greater for patients with type 1 diabetes than those with type 2 diabetes. While young patients are at increased risk for DKA, studies have shown that these patients have lower rates of severe COVID-19. Data on the risk for DKA in patients with COVID-19 are limited and a single study reported that 7% of 658 hospitalized patients with COVID-19 had DKA.

While DKA is frequently associated with marked hyperglycemia, this feature may be absent when the cause of DKA is the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors. In these cases, DKA may occur at glucose levels ≤250 mg/dL. Individuals using SGLT2 inhibitors during the COVID-19 pandemic may be at increased risk for DKA; it is important to advise these patients to discontinue these medications at the first sign of severe flu-like illness.

The treatment of DKA includes 3 main components: fluid resuscitation, potassium repletion, and insulin treatment. Bicarbonates are not routinely recommended and are mainly used in patients with severe acidosis (pH <6.9).

Unique considerations during the COVID-19 pandemic include efforts to provide the recommended treatment while minimizing contact between the medical team and patients in order to reduce the risk for contracting the infection and preserve personal protective equipment. In addition, while intravenous insulin is usually recommended for DKA therapy, there are data supporting the safety and efficacy of subcutaneous rapid-acting insulin for DKA. For these reasons, subcutaneous insulin therapy has been used in patients with uncomplicated, mild or moderate DKA.

Intravenous insulin therapy should be used in patients with severe DKA and those with significant comorbidity, such as end-stage renal disease, severe acute kidney injury, myocardial infarction, or stroke. Furthermore, insulin should be given intravenously to pregnant persons and to those who require an intensive care unit (ICU) level of care for other reasons.

Severe DKA also requires close monitoring with frequent glucose testing and laboratory monitoring. While the recommendation is to measure glucose levels every 1 to 2 hours, in many institutions, the frequency of glucose monitoring has been decreased and/or continuous glucose monitoring devices have been used to minimize contact between patients and healthcare workers.

It should be noted that several reports have described higher than usual insulin requirements in critically ill patients with COVID-19. In addition, treatment modalities in the ICU setting can also affect insulin needs, requiring frequent adjustments of insulin therapy.

In light of the continual monitoring and adjustments needed for intravenous insulin treatment, the ICU is the recommended hospital setting for patients with severe DKA. On the other hand, stable patients with mild DKA who are able to take oral fluids and self-manage early DKA can do so at home. However, as patients with COVID-19 may deteriorate rapidly, referral for urgent assessment is reasonable when a home ketone test is positive.

Recommendations for patients with diabetes to prevent DKA during the COVID-19 pandemic include sustaining their insulin regimen, reassessing oral therapies, and ketone testing during acute illness for insulin-deficient patients and those taking SGLT2 inhibitors. Furthermore, patients should have a 3-month supply of medications and all required equipment on hand at home.

Initiating insulin treatment should not be postponed during the pandemic when it is clearly indicated, such as in patients who have DKA as the presenting symptom of new-onset diabetes. Education on insulin use should be furnished in person or using telemedicine.

While some services that potentially reduce DKA risk, including early screening and family-level education, may not available during the current pandemic, telemedicine has been shown to be an appropriate tool to prevent DKA and treat patients with diabetes. It is also very important that all parties involved in the management of diabetes help patients with diabetes to continue their insulin therapy.

“Further studies are needed to explore the incidence and pathogenesis of DKA in patients with [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] infection,” wrote the authors of the perspective article.

Reference

Palermo NE, Sadhu AR, McDonnell ME. Diabetic ketoacidosis in COVID-19: unique concerns and considerations [published online June 18, 2020]. J Clin Endocrinol Metab. doi:10.1210/clinem/dgaa360