Diabetic Ketoacidosis in COVID-19: Unique Concerns and Considerations

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Context</jats:title> <jats:p>While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign.</jats:p> </jats:sec> <jats:sec> <jats:title>Case Description</jats:title> <jats:p>This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.</jats:p> </jats:sec>

COVID-19-associated euglycemic diabetic ketoacidosis in a patient with type 2 diabetes on SGLT2 inhibitor: a case report

“…There are two case reports of eu-DKA in the setting of SARS-CoV-2 infection and SGLT2 inhibitor use [ 17 , 21 ], but we would like to emphasize some differences this report presents. The first difference is that the patient investigated in the present case report has T2DM and developed eu-DKA even without being on previous use of insulin.…”

“…It is still unclear whether or not there is a higher prevalence of DKA and which mechanism of COVID-19 can induce ketoacidosis [ 16 ]. Both DKA and COVID-19 have high levels of inflammatory markers, including IL-6, which have been related to the severity of SARS-CoV-2 infection and with the development of DKA [ 17 ].…”

“…and Bornstein et al . had a broader approach and suggested discontinuing SGLT2 inhibitors in the context of COVID-19 infection at the first signs of the illness, regardless of insulin use status, in an attempt to avoid the development of ketoacidosis and acute metabolic decompensation [ 17 , 18 ]. Nevertheless, it is described on medical literature that the pharmacological effects of these drugs can persist for several days [ 20 ].…”

Endocrinology and Covid-19: A Multifaceted Interaction

“…Early reports suggest that severe COVID-19 infection may be associated with increased risk of diabetic ketoacidosis, which is associated with a grave prognosis. 27 This calls for greater vigilance with regard to acute hyperglycemic emergencies in patients with COVID-19 infection and their prompt diagnosis and aggressive management. In resource-limited settings, where use of IV insulin infusion is not feasible, frequent subcutaneous injections of rapid-acting insulin analogs can be considered along with IV fluids in mild-moderate DKA.…”

“…In resource-limited settings, where use of IV insulin infusion is not feasible, frequent subcutaneous injections of rapid-acting insulin analogs can be considered along with IV fluids in mild-moderate DKA. 27…”