Preventing Ketoacidosis Complications in Diabetes

Diabetic ketoacidosis (DKA) a hyperglycemic crisis most commonly associated with type 1 diabetes mellitus (T1DM) is often the first symptom of diabetes to appear in the undiagnosed population. Managing the condition effectively to prevent incidence is important because of the associated mor-bidity and resulting economic impact.¹ Studies have shown that hospitalizations resulting from DKA amount to an annual cost of more than $2.4 billion in the United States.¹

THE PATHOLOGY BEHIND KETOACIDOSIS?

Reduced concentrations of effective insulin and increased amounts of coun-ter-regulatory hormones. Since the body cannot break down and use sugar as an energy source, it draws energy from fat tissue; increased lipolysis releases free fatty acids in the blood and causes oxi-dation of hepatic fatty acids to ketone bodies, resulting in ketonemia and metabolic acidosis.^1,2

DKA is also observed in type 2 diabetes mellitus (T2DM) patients, most of-ten a result of uncontrolled blood sugar, missed doses of insulin, or a comorbidity. If left untreated, DKA can lead to cerebral edema, heart attack, pulmonary or gastrointestinal complications, or kidney failure.^2,3

INCIDENCE OF DKA

Multiple studies have determined that socioeconomic status can greatly influ-ence patients’ insulin compliance. One investigation, which focused on adult patients from an innercity area, found poor compliance to be dictated by be-havioral, socioeconomic, psychosocial, and educational factors. The authors concluded that culturally appropriate interventions and education programs could remedy DKA recurrence in this population.⁴

DKA is quite common in the younger population, according to a study published last year in Pediatrics that reported results from a multi-center surveillance conducted between 2002 and 2010 across the United States. The analysis, based on data from 5615 individuals under 20 years of age, revealed an increased incidence of DKA in the T1DM population compared with T2DM, indicating a possible earlier diagnosis or im-proved detection of the T2DM. The survey found that diagnosis of DKA among youth with T1DM in the Unites States remained high compared with other developed countries, with the highest incidence observed in:

• Children less than 5 years of age

• Non-white ethnic groups

• Youth not covered by private health plans

• Youth from low-income families.

Based on their findings, the authors recommended improving people’s awareness of the ways to recognize the signs and symptoms of diabetes, along with improving the population’s access to healthcare. Referring to the provisions of the Affordable Care Act (ACA) that would make healthcare more accessible, the authors predicted a reduction in DKA rates, but warned that minority groups might need additional outreach activities to achieve significant improvements.⁵

A more recent report in JAMA, based on data collected between 1998 and 2012 in Colorado, showed that DKA was present in nearly 40% of those newly diagnosed with T1DM before age 18 years, and the incidence increased from 29.9% in 1998 to 46.2% in 2012. Significant risk factors included younger age and race (African American). Conversely, those covered by private insurance had a lower risk of DKA, as were youth who had a first-degree relative diagnosed with T1DM.⁶

However, between 2007 and 2012, pri-vate insurance was associated with a 2.5% increase in DKA per year, and pub-lic insurance a 1.3% decrease per year. The authors wrote: “The recent increase of DKA incidence among youth with pri-vate insurance may be related to prolif-eration of high-deductible health plans.” While the authors acknowledged that it may not be possible to generalize re-sults gathered from a single state, they suggested that additional studies are needed to make clear both the reasons behind the increase in DKA incidence and the interventions necessary for re-ducing incidence.⁶

The results might actually be more generalizable than the authors presumed. A retrospective evaluation of 167 patients admitted to a pediatric intensive care unit in Charleston, West Virginia, identified socioeconomic fac-tors as major contributors to children (average age, 13.5 years) being admitted for DKA. High glycated hemoglobin, race (African American), and insurance coverage through Medicaid/CHIPS (indica-tive of low socioeconomic status) were high risk factors for children being diag-nosed with DKA.⁷

PREVENTING DKA

A look at some of the risk factors associated with the incidence of DKA among young children indicates that most of these variables cannot be controlled. Race and socioeconomic strata, for ex-ample, cannot be altered. However, identifying the population most vulnerable to a particular condition might help direct services to a specific subset of the population and help reduce in-cidence. In this case, raising awareness about DKA, educating patients on diabetes self management, and ensuring appropriate interventions could prevent incidence of this condition in the young T1DM population. Equally important is ensuring adequate access to healthcare so that patients don’t miss or skip medi-cation doses.

Importantly, provisions within the ACA have included DKA a manifestation of poor glycemic control in the list of hospital-acquired conditions (HACs). HACs are program measures that rate a hospital’s performance and determine their inpatient reimbursement to ensure that providers pay attention to preventable conditions.⁸

References

1. Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014;7:255-264.

2. Diabetic ketoacidosis. MedlinePlus website. http://www.nlm.nih.gov/medlineplus/ency/ar-ticle/000320.htm. Accessed April 25, 2015.

3. Bialo SR, Agrawal S, Boney CM, Quintos JB. Rare complications of pediatric diabetic ketoacidosis.World J Diabetes. 2015;6(1):167-174.

4. Randall L, Begovic J, Hudson M, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care. 2011;34(9):1891-1896.

5. Dabelea D, Rewers A, Stafford JM, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics. 2014;133(4):e938-e945.

6. Rewers A, Dong F, Slover RH, Klingensmith GJ, Rewers M. Incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in Colorado youth, 1998-2012. JAMA. 2015;313(15):1570-1572.

7. Lewis KR, Clark C, Velarde MC. Socioeconomic factors associated with pediatric diabetic ketoacidosis admissions in Southern West Virginia. Clin Endocrinol (Oxf). 2014;81(2):218-221.

8. Affordable Care Act’s Hospital Acquired Condi-tion (HAC) provisions. http://fpdi.org/affordable-care-acts-hospital-acquired-condition-hac-provisions/. Published February 8, 2015. Accessed April 27, 2015.

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