Characteristics of Hyperglycemic Emergencies in COVID-19

Novel coronavirus disease 2019 (COVID-19) is associated with hyperglycemic emergencies, particularly in patients with existing type 2 diabetes and of African ethnicity, according to a case series published in The Lancet Diabetes & Endocrinology.

Diabetes is a significant risk factor for severe disease in patients with COVID-19. In a retrospective case series of 35 patients (22.9% women; 40.0% African ethnicity) treated at 3 hospitals in north London, United Kingdom, investigators reported the characteristics of hyperglycemic emergencies occurring within the context of COVID-19.

The majority of patients presented with diabetic ketoacidosis (DKA; 31.4%) or mixed DKA and hyperosmolar hyperglycemic state (37.1%). An additional 25.7% presented with hyperglycemic ketosis and 5.7% presented with hyperosmolar hyperglycemic state alone. The median overall hemoglobin A1c was 111 mmol/mol.

Type 2 diabetes was prevalent in 80% of patients, while 14.3% had a history of type 1 diabetes with DKA and 2 patients had a new presentation of diabetes. Before hospitalization, 12 patients (34.3%) were on insulin treatment and 2 patients (5.7%) were on sodium-glucose cotransporter 2 (SGLT2) inhibitors.

Across all groups, the degree of ketonemia was negatively correlated with serum bicarbonate levels and base excess and positively associated with alanine aminotransferase levels. The median time to ketone resolution was highest in patients with DKA (35 hours; interquartile range [IQR], 24-60 hours).

Time to ketone resolution was positively associated with prothrombin time, activated partial thromboplastin time, and fluid volume required and was negatively associated with pH, bicarbonate levels, and base excess.

The median time to intensive care unit admission was 3.0 days (95% CI, 0.6-5.4). The median length of stay for discharged patients was 18.0 days (95% CI, 10.2-25.8). At the time the report was released, 13 patients were still inpatients and 2 had died. Of the 2 patients that died, 1 had DKA and 1 had mixed DKA and hyperosmolar hyperglycemic state.

The researchers noted that levels of cortisol and C-peptide were not assessed, representing a potential limitation to their findings.

“COVID-19 is associated with [hyperglycemic] emergencies in COVID-19 with overrepresentation of type 2 diabetes in patients presenting with DKA and long-lasting ketosis,” the study authors concluded. “Further large-scale observational studies are needed to elucidate the diabetogenic effects of COVID-19, and the impact of factors such as medication adherence, [glycemic] control pre- and during hospitalization and ethnicity on the development of COVID-19.”

They added that “an interplay between ethnicity and ketogenesis cannot be excluded. Even though our sample size was small to identify statistical differences, almost half of our sample consisted of patients with African or Afro-Caribbean descent, which might explain at least in part the profound [ketonemia] on admission.”

Reference

Armeni E, Aziz U, Qamar S, et al. Protracted ketonaemia in hyperglycaemic emergencies in COVID-19: a retrospective case series [published online July 1, 2020]. Lancet Diabetes Endocrinol. doi:10.1016/S2213-8587(20)30221-7