Management Of Diabetic Ketoacidosis Research Articles

8725 Subcutaneous Compared With Intravenous Insulin Protocol For Management Of DKA: A Longitudinal Experience In A Single Center

Abstract Disclosure: S. Avula: None. M. Salim: None. E. Wetherbee: None. C. Wenner: None. A. Gravely: None. A.D. Westanmo: None. N.G. Ercan-Fang: None. Background: Diabetic ketoacidosis (DKA) is a critical condition requiring immediate medical attention to prevent severe health complications and even death. Typically, patients are placed under the care of the intensive care unit (ICU) to ensure close supervision. With implementation of effective subcutaneous insulin protocol (SIP), patients can be safely managed outside of ICU without any significant change in mortality or morbidity, potentially decreasing financial burden of costly ICU stay. Aim: To review and compare the experience with subcutaneous and intravenous insulin protocols for management of DKA at Minneapolis Veterans Affairs Health Care System (MVAHCS). Methods: We conducted a retrospective chart review of patients who were admitted with DKA at MVAHCS from 2013 - 2023 and were treated with either I.V insulin or SIP. Inclusion criteria: Adults (age >/=18 years) admitted with DKA between 2013 and 2023. Exclusion criteria: Non availability of VBG/ABG and patients who were not treated initially at MVAHCS. Statistical analysis used was basic descriptive analysis, Pearson’s Chi-Square and Two sample T test. Results: Majority of patients included were males: 57 (96.61%) and 16 (88.89) in SIP and I.V insulin, respectively. Racial distribution of patients was skewed towards a white population: Total of 57 (74.03%) were white, 12 (15.58%) were African American (AA). A significant majority of white patients 47 (79.66%) were on SIP, while 10 (55.56%) were on I.V insulin. Mean age of SIP and I.V insulin study populations were 58.9 (SD 16.21) and 59.2 years (SD 12.23), respectively. Baseline mean pH of the SIP and I.V insulin study populations were 7.27 (SD 0.08) and 7.13 (0.13), respectively. Mean bicarb for SIP was 14.9 mEq/L (SD 4.60) and I.V Insulin was 10.1 mEq/L ( SD 4.57). Mean time for anion gap (AG) closure among patients on SIP was modestly higher at 19.7 hours (SD 15.3) when compared to that on I.V insulin of 17.1 hours (SD 12.4) but the difference did not reach statistical significance. Similarly, 55.6% (n=10) of patients on I.V insulin and 58.6% (n=34) of those on SIP had anion gap closure of >/= 12 hours (p = 0.8187). When adjusted for baseline pH and bicarbonate, 46% of patients in the I.V insulin group had AG closure >=12 hours, whereas 67% of those in the SIP group had AG closure >=12 hours with total difference of 21% (p= 0.2098). Conclusion: Our results demonstrate that SIP can be safely implemented outside of the ICU setting. Compared with SIP, baseline pH was slightly less in the IV group (our protocol directs sicker patients with lower baseline pH towards the I.V insulin rather than SIP), however, AG closure time was similar between the two groups even after performing multiple regression analysis where we adjusted for baseline differences between two treatment groups in pH, bicarbonate, AG. These results indicate that SIP could be safe and potentially cost saving alternative for DKA management. Presentation: 6/3/2024

6844 Comparison of Lactated Ringers and Normal Saline in the Treatment of Diabetic Ketoacidosis

Abstract Disclosure: J.N. Johnson: None. A.T. Drincic: None. K. Nein: None. E. Buddenhagen: None. K. Samson: None. T. Langenhan: None. Background: Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. We hypothesized that the use of LR compared to NS for volume management in DKA will shorten time to DKA resolution, reduce time to DKA associated protocol insulin infusion discontinuation, and result in lower post-intravenous fluid resuscitation chloride values. Methods: We conducted a single institution, retrospective cohort study of patients admitted with the diagnosis of DKA following our institution’s transition from NS to lactated ringers (LR) as the default resuscitative and maintenance fluid in our DKA management protocol. Adult patients admitted with DKA before and after the protocol change were identified. The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol continuous insulin infusion. Results: Of 246 patients meeting inclusion criteria, 119 were stratified to the NS group (pre-protocol change) and 127 to the LR group (post-protocol change). T-test analysis revealed decreased time to DKA resolution in the LR group (mean 17.1 hours; SD 11.02) relative to the NS group (mean 20.6 hours; SD 12.22; p = .02). Duration of DKA protocol continuous intravenous insulin was shorter in the LR group (mean 16.0 hours; SD 8.72) compared to the NS group (mean 21.4 hours; SD 12.50; p = 0.0001). Conclusions: In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol continuous insulin infusion. Presentation: 6/2/2024

Continuous ketone monitoring: Exciting implications for clinical practice.

Diabetic ketoacidosis (DKA) is a life-threatening complication usually affecting people with type 1 diabetes (T1D) and, less commonly, people with type 2 diabetes. Early identification of ketosis is a cornerstone in DKA prevention and management. Current methods for ketone measurement by people with diabetes include capillary blood or urine testing. These approaches have limitations, including the need to carry testing strips that have a limited shelf life and a requirement for the user to initiate a test. Recent studies have shown the feasibility of continuous ketone monitoring (CKM) via interstitial fluid with a sensor inserted subcutaneously employing an enzymatic electrochemical reaction. Ketone readings can be updated every 5 minutes. In the future, one would expect that commercialized devices will incorporate alarms linked with standardized thresholds and trend arrows. Ideally, to minimize the burden on users, CKM functionality should be integrated with other devices used to implement glucose management, including continuous glucose monitors and insulin pumps. We suggest CKM provision to all at risk of DKA and recommend that the devices should be worn continuously. Those who may particularly benefit are individuals who have T1D, are pregnant, on medications such as sodium-glucose linked transporter (SGLT) inhibitors that increase DKA, people with recurrent DKA, those with T1D undertaking high intensity exercise, are socially or geographically isolated, or those on low carbohydrate diets. The provision of ketone profiles will provide important clinical insights that have previously been unavailable to people living with diabetes and their healthcare professionals.

A regional audit of diabetic ketoacidosis (DKA) presentations at diagnosis of type 1 diabetes (T1DM) and DKA management

A regional audit of diabetic ketoacidosis (DKA) presentations at diagnosis of type 1 diabetes (T1DM) and DKA management

Audit of management of diabetic ketoacidosis in children and young people at the noah's ark children's hospital for wales

Audit of management of diabetic ketoacidosis in children and young people at the noah's ark children's hospital for wales

Audit on diabetic ketoacidosis (DKA) management in county hospital navan

Audit on diabetic ketoacidosis (DKA) management in county hospital navan

Early Versus Late Administration of Long-Acting Insulin in Adult Diabetic Ketoacidosis.

Evidence is inconclusive if early administration of subcutaneous (SQ) long-acting insulin (LAI) in management of diabetic ketoacidosis (DKA) improves outcomes. This study compares early versus late administration of SQ LAI in time to DKA resolution. This single-center, retrospective study included patients with DKA who received ≥12 hours of continuous intravenous insulin (CIVI) with LAI overlap. Patients were compared based on LAI administration time to CIVI initiation: Early (<12 hours) versus Late (≥12 hours). The DKA resolution is defined as blood glucose < 200 mg/dL and 2 of the following: anion gap < 12 mEq/L, pH > 7.35, or serum carbon dioxide >15 mEq/L. Outcomes included time to DKA resolution, length of stay (LOS), CIVI duration, and adverse events. A total of 27 patients were included in each group. Baseline characteristics were similar between both groups. There was no difference in time to DKA resolution, Early = 17.6 (13.9-26.8) hours versus Late = 19.2 (17.1-32.1) hours, P = 0.16. The Early group had shorter CIVI duration (Early = 19.5 ± 10.3 hours vs Late = 25.6 ± 8.4 hours, P = 0.02) and received less intravenous (IV) fluids in the first 36 hours (Early = 4.04 ± 2.12 L vs Late = 5.85 ± 2.24 L, P = 0.004). No differences were identified with adverse events, including hypoglycemia, or LOS. Administration of SQ LAI < 12 hours did not decrease time to DKA resolution or LOS. Patients in the Early group had received a lower dose of LAI, shorter duration of CIVI infusion, and required less IV fluids within 36 hours of admission. This study supports the need for further research to determine the potential benefits of administering SQ insulin early in managing DKA.

Balanced Crystalloid (Sterofundin) vs. Normal Saline for Diabetic Ketoacidosis: A Prospective Intervention Trial with Historical Controls.

Fluid therapy with normal saline (NS) in diabetic ketoacidosis (DKA) can cause hyperchloremic acidosis and delay DKA resolution. Balanced crystalloids may address this concern, though results with Ringer lactate and Plasma-Lyte have been mixed. This study aimed to compare the effectiveness of Sterofundin (SF) vs. NS in the management of DKA. A prospective, intervention trial with historical controls was conducted at the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Patients aged 13 years or older with DKA were enrolled. The primary outcome was the time taken to DKA resolution, with a predefined superiority margin of a one-fourth reduction in resolution time. Secondary outcomes included total intravenous fluid and short-acting regular insulin requirements, the need for 0.45% saline, hospital stay duration, and in-hospital mortality. A total of 150 patients (mean age 36.8 years, 56.7% males) were included, with 75 receiving SF (intervention group) and 75 receiving NS (historical control group). The SF group showed a significantly shorter mean time to DKA resolution (13.8 ± 6.0 hours) compared to the NS group (18.1 ± 5.5 hours; P < 0.001). SF patients required less total intravenous fluid (4500 mL vs. 6000 mL; P = 0.004), less insulin (98 units vs. 112 units; P = 0.017), and had a lower need for 0.45% saline (8% vs. 74.3%; P < 0.001). Patients receiving SF had shorter hospital stays (4 [IQR 3-5] days vs. 4 [IQR 4-6] days; P = 0.020). Mortality rates were similar between the groups (SF: 9.3%, NS: 8.1%; P = 0.791). SF may be a superior alternative to NS for fluid therapy in DKA.

Eruptive Xanthoma as Alarming Sign of Hypertriglyceridemia in Poorly Controlled Type 2 Diabetes Mellitus

Eruptive xanthomas may be the phenotypic expression of severe hypertriglyceridemia and are usually located on the surfaces of the extensor areas and buttocks. We present a case of eruptive xanthomas in the extensor areas of the arms and legs associated with severe hypertriglyceridemia in an adolescent diagnosed with diabetes mellitus who was admitted for diabetic ketoacidosis (DKA). After the management of DKA, the use of maintenance insulin therapy and lipid-lowering agents were initiated with a marked reduction in triglycerides and significant improvement in eruptive xanthomas. Proper management of DM and rapid reduction of triglyceride levels were essential in preventing complications such as acute pancreatitis. This article highlights the importance of an adequate management of the diabetic patient and the clinical suspicion of severe hypertriglyceridemia in patients with eruptive xanthoma.

Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitor-Related Euglycemic Diabetic Ketoacidosis: A Case Series.

Objectives: Sodium-glucose transporter-2 inhibitors (SGLT2i) are commonly used for the treatment of Type 2 Diabetes Mellitus, offering additional benefits in non-diabetic patients with conditions such as chronic kidney disease and heart failure. However, SGLT2i have been associated with an increased risk of euglycemic diabetic ketoacidosis (DKA). This case series describes three cases of patients who developed euglycemic DKA while taking SGLT2i. Key Findings: Each of the three patients with euglycemic DKA were taking SGLT2i for the treatment of diabetes and all had additional risk factors for the development of DKA. These factors included reduced oral intake, major acute illness, chronic pancreatitis, and a history of previous DKA episodes. Unfortunately, the absence of hallmark symptoms like hyperglycemia, polyuria, and polydipsia led to delayed diagnosis of euglycemic DKA in two of the three patients. Conclusion: Early recognition of risk factors and a high level of suspicion are critical in identifying euglycemic DKA in patients taking SGLT2i. Healthcare providers should conduct thorough medication reconciliation upon admission and closely monitor patients for concurrent issues, especially in cases of minimal oral intake, acute illnesses, and chronic pancreatitis. Prompt diagnosis and management of euglycemic DKA can significantly improve patient outcomes.

Management of diabetic ketoacidosis in children: Does early insulin glargine help improve outcomes?

Rebound hyperglycemia following the resolution of diabetic ketoacidosis (DKA) is common in pediatric patients with type 1 diabetes, increasing the risk of recurrent DKA and complicating the transition to subcutaneous insulin. Multiple studies suggest that early administration of long-acting insulin analogs during DKA management safely improves this transition. This study aimed to determine whether early insulin glargine administration in children with DKA prevents rebound hyperglycemia and recurrent ketosis without increasing the rate of hypoglycemia or hypokalemia. Patients aged <21 years presenting with DKA to Children's Mercy Kansas City between October 2012 and October 2016 were reviewed. They were categorized as Early (>4 h of overlap with intravenous [IV] insulin) and Late (<2 h of overlap) cohorts. We reviewed 546 DKA admissions (365 Early and 181 Late). Rebound hyperglycemia (>180 mg/dL) was lower in the Early group (66% vs. 85%, p ≤ 0.0001). Hypoglycemia (<70 mg/dL) during IV insulin administration was higher in the Early group than in the Late group (27% vs. 19%, p = 0.042). Hypoglycemia within 12 h of IV insulin discontinuation was lower in the Early group (16% vs. 26%, p = 0.012). Recurrent ketosis, hypokalemia, and cerebral edema were not different between the groups. Early glargine administration in pediatric DKA management is safe, decreases the rate of rebound hyperglycemia, and improves the transition to subcutaneous insulin. Hypoglycemia is less frequent following IV insulin discontinuation with early glargine, but the IV insulin rate may need to be reduced to minimize hypoglycemia during IV insulin infusion.

Lactated Ringer's versus normal saline in the management of acute diabetic ketoacidosis (RINSE-DKA).

A mainstay in the acute management of diabetic ketoacidosis (DKA) is fluid resuscitation. Normal saline is recommended by the American Diabetes Association; however, it has been associated with hyperchloremic metabolic acidosis and acute kidney injury. Limited literature is available to determine the most appropriate crystalloid fluid to treat patients with DKA. The purpose of this study was to compare lactated Ringer's (LR) to normal saline (NS) in the acute management of DKA. This was a retrospective, multicenter single health system cohort study. The primary outcome was to evaluate the time to high anion gap metabolic acidosis (HAGMA) resolution using LR compared to NS. Secondary outcomes included the incidence of nongap metabolic acidosis, hyperchloremia, acute kidney injury, and new renal replacement therapy. Other secondary outcomes included insulin infusion duration and hospital and intensive care unit length of stay. The Cox proportional hazards model was used for the primary outcome. A total of 771 patient encounters were included. Lactated Ringer's was associated with faster time to HAGMA resolution compared to NS (adjusted hazard ratio 1.325; 95% confidence interval 1.121-1.566; p < 0.001). No difference was found in complications such as incidence of nongap metabolic acidosis, hyperchloremia, acute kidney injury, and new renal replacement therapy between the LR and NS groups. Additionally, there was no difference in insulin infusion duration and hospital or intensive care unit length of stay. Treatment with LR as the primary crystalloid for acute DKA management was associated with faster HAGMA resolution compared with NS. Similar incidence in complications and length of stay was observed between the two groups. The findings of this study add to the accumulating literature suggesting that balanced crystalloids may offer an advantage over NS for the treatment of patients with DKA.

Review of Subcutaneous Insulin Regimens in the Management of Diabetic Ketoacidosis in Adults and Pediatrics.

Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics. A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*. Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded. The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics. In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations. Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.

Comparison of clinical characteristics and treatment outcomes between initially diagnosed type 1 and type 2 diabetes mellitus patients presenting with diabetic ketoacidosis

ObjectivePatients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) can present with diabetic ketoacidosis (DKA) as the first manifestation. Differentiating types of newly diagnosed diabetes could provide appropriate long-term management. Therefore, we conducted this study to compare clinical characteristics and outcomes between initially diagnosed type 1 and type 2 diabetes mellitus patients presenting with DKA.Materials and methodsA retrospective study was conducted on adult patients who presented with DKA as the first diagnosis of diabetes in our tertiary hospital between January 2005 and December 2019. Demographic data, precipitating causes, laboratory investigations, treatment, and outcomes were obtained by chart review. The primary outcome was to compare the clinical characteristics of initially diagnosed patients with T1DM and T2DM who presented with DKA.ResultsA total of 100 initially diagnosed diabetic patients who presented with DKA were analyzed (85 T2DM patients and 15 T1DM patients). Patients with T1DM were younger than patients with T2DM (mean age 33 ± 16.2 vs. 51 ± 14.5 years, p value < 0.001). Patients with T2DM had a higher body mass index, family history of diabetes, precipitating factors, plasma glucose, and lower renal function than those with T1DM. There was no difference in resolution time or DKA management between T1DM and T2DM patients. The overall mortality rate of DKA was 4%.ConclusionIn this population, most adult patients who presented with DKA had T2DM. Older age, obesity, a family history of diabetes, and the presence of precipitating factors were strong predictors of T2DM. We can implement the same clinical management for DKA in both T1DM and T2DM patients. However, T2DM patients had longer hospitalization than T1DM patients. After DKA resolution for 12 months, more than half of patients with T2DM could discontinue insulin. Therefore, the accurate classification of the type of diabetes leads to appropriate treatment.

The Effects of Subcutaneous Rapid-Acting Insulin Aspart in the Treatment of Mild and Moderate Diabetic Ketoacidosis in Children: A Prospective Study.

Background and objectives The traditional treatment approach to diabetic ketoacidosis (DKA) involves the replacement of fluid and electrolyte deficits and a continuous intravenous infusion of regular insulin. Several clinical trials supported the administration of subcutaneous rapid-acting insulin analogs in the management of uncomplicated DKA. This study aimed to determine the effects/safety of subcutaneous rapid-acting insulin aspart injections in treating uncomplicated mild and moderate DKA in children. Methods In this prospective study in 2022, 25 children with mild/or moderate DKA were enrolled. The main outcome measure was median time (hours) for the resolution of ketoacidosis. Data recorded were as follows: clinical characteristics, severity of ketoacidosis and dehydration, blood glucose, sodium, potassium, creatinine, urine ketones, hospitalization's duration, and complications. Based on the degree of dehydration, fluid deficit was replaced by sodium chloride 0.45%. Insulin aspart 0.15 units/kg subcutaneous injections were given every 2 hours in the hospital outside ICU. Blood glucose was measured hourly and blood gases every 2 hours. Ketoacidosis was considered resolved when the patient did not have nausea/vomiting, was conscious, and could eat, and blood glucose was <250 mg/dL, pH was >7.30, and/or HCO3 was >15 mmol/L. Results Of 25 DKA patients (mean age 11.06±3.89, range 4-17 years, 60% girls), 16 cases (64%) had established type 1 diabetes. Overall, 13 (52%) cases had mild ketoacidosis (average pH=7.25), and 12 (48%) cases had moderate ketoacidosis (average pH=7.15). The mean time to resolution of ketoacidosis was 11.24 hours. All but one patient met DKA recovery criteria without complications. Mild cases compared to moderate cases of DKA had a shorter duration to resolution of DKA (p = 0.04). Mean duration of hospitalization was 2.3 days. No electrolyte disturbances, hypoglycemia events, readmission or mortality, or other adverse effects were observed. Conclusion In children with mild and moderate DKA, subcutaneous rapid-acting insulin aspart administration was an effective, safe, and convenient treatment.

Analysis of the 2-Bag Method for the Management of Diabetic Ketoacidosis: A Retrospective before and after Study.

Purpose: This study aims to assess the efficacy and safety of a two-bag method compared with a one-bag method for the treatment of diabetic ketoacidosis (DKA). We hypothesize that a two-bag method will decrease the incidence of hypoglycemia, when compared with a one-bag method. Methods: A retrospective chart review was conducted on patients treated for DKA at a Trinity Health institution between 2020 and 2022. A total of 1084 adult patients were included. Patients treated with the one-bag protocol were included in the pre-group, while those treated with the two-bag protocol were included in the post-group. The primary outcome was incidence of hypoglycemia (blood glucose <70mg/dL). Secondary outcomes included time to anion gap closure, insulin infusion duration, time to HCO3 correction, and incidence of hypokalemia. Patients were excluded if they were pregnant or diagnosed with Hyperosmolar Hyperglycemic State (HHS), euglycemic DKA, or ketosis from other causes. Results: The incidence of hypoglycemia was 38% in the pre-group and 15.83% in the post-group (P < .001). Patients in the pre-group were on an insulin infusion longer than the post-group (28.37hours vs 22.17hours, P < .001). Patients in the pre-group had a slower time to anion gap closure (8.99 hours vs 8.52hours, P = .021) and had a slower time to HCO3 correction (10.88hours vs 10.69hours, P = .004). Between-group incidence of hypokalemia was similar (66.39% vs 60%, P = .079). Conclusions: The two-bag method for the treatment of DKA resulted in improved safety and efficacy outcomes, compared with the one-bag method.

Outcomes of a tele-intensive care unit pharmacist on the management of diabetic ketoacidosis.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The tele-intensive care unit (tele-ICU) pharmacist facilitates patient-specific diabetic ketoacidosis (DKA) treatment utilizing guideline-directed therapy. This study was designed to determine how patient-specific interventions by a tele-ICU pharmacist affected patients with DKA compared to the standard of care. This retrospective cohort study utilized custom reports and manual chart review to evaluate the electronic health records of patients 18 years or older who received continuous intravenous insulin and were admitted for DKA between January 2019 and December 2020. The primary endpoint was time to DKA resolution, defined by the patient meeting at least 2 of the following criteria: a serum bicarbonate concentration of at least 18 mEq/L, an arterial pH of greater than 7.3, and closure of the anion gap (less than or equal to 12 mEq/L). Patients treated with tele-ICU pharmacist patient-specific interventions reached DKA resolution 7.32 hours earlier than patients treated with the standard of care (22.16 vs 29.48 hours; P = 0.0019). There was no statistically significant difference between the groups for ICU length of stay, time until subcutaneous insulin administration, incidence of hypoglycemia, incidence of severe hypoglycemia, and sodium bicarbonate use. In patients who received a tele-ICU pharmacist intervention, there was a statistically significant increase in the volume for fluid resuscitation and the amount of total continuous insulin infused after ICU admission and a statistically significant reduction in the time between laboratory draws. Treatment of patients with tele-ICU pharmacist patient-specific interventions was associated with faster DKA resolution, more frequent laboratory monitoring, and a higher volume of insulin and fluids infused than in patients treated with protocol-driven therapy.

Ketosis-prone Diabetes Presenting with Acute Esophageal Necrosis or “Black Esophagus”: An Intriguing New Clinical Association

Background:: Ketosis-prone diabetes (KPD) is an intermediate subtype of diabetes mellitus, usually affecting Afro-American adults, presenting with diabetic ketoacidosis (DKA), without the classic phenotype of autoimmune type 1 diabetes. Patients require insulin therapy at onset for the acute decompensation, then usually remain insulin-free for prolonged periods with diet alone or with other antidiabetic drugs. DKA can be rarely complicated by upper gastrointestinal bleeding and mucosal necrosis, a severe complication named acute esophageal necrosis (AEN) burdened by high mortality. The association of KPD presenting with DKA complicated by AEN is here reported for the first time, to the knowledge of the authors, in the medical literature. Case Presentation:: Here we report an interesting case of middle-aged African woman, newly diagnosed with KPD, presenting with DKA hematemesis. The patient was first treated at Intensive Care Unit for the ketoacidosis with intravenous fluids combined with continuous insulin infusion, and then switched to subcutaneous regimen. At the same time, esophagogastroduodenoscopy (EGD) was performed to diagnose acute esophageal necrosis, which was promptly managed with proton pump inhibitors infusion, fasting, and parenteral nutrition. After the correct clinical evaluation, the patient was switched to oral antidiabetic and basal insulin at discharge and an EGD follow-up was scheduled. Conclusions:: KPD remains an under-recognized and under-diagnosed type of diabetes which can present as DKA. Since DKA could be a possible trigger of AEN, a rare but potentially lifethreatening condition, that clinicians should be aware of, in patients presenting with upper gastrointestinal bleeding and ketoacidosis. The prompt management and classification of DKA, combined with the EGD execution for early AEN diagnosis and follow-up, is essential.

Addressing olanzapine-induced diabetic ketoacidosis in a major depressive disorder case

This case study highlights a critical incidence of olanzapine-induced diabetic ketoacidosis (DKA) in a 36-year-old female patient treated for major depressive disorder with psychotic features. The patient developed severe DKA after the initiation of olanzapine, despite initially normal metabolic parameters and a low starting dose. This report underscores the acute metabolic derangement facilitated by olanza- pine, necessitating a comprehensive and urgent medical approach. The clinical intervention involved discontinuing olanzapine and initiating a multidisciplinary treatment strategy, which included medical management of DKA and psychiatric adjustments using alternatives with a lower metabolic risk. This case emphasizes the necessity for regular metabolic monitoring and the potential need for tailored psychiatric medication strategies to prevent severe side effects, highlighting the unpredictability of antipsychotic- induced metabolic disturbances and advocating for a holistic, patient-centered approach in psychiatric care.

Impact of diabetic ketoacidosis on outcomes in hospitalized diabetic patients with Clostridioides difficile infection: a national inpatient analysis

Introduction Diabetic ketoacidosis (DKA) is a critical diabetic emergency with life-threatening complications. The impact of DKA on hospital outcomes in diabetic patients with Clostridioides difficile infection (CDI) remains unclear. Methods This retrospective analysis used data from the 2016 to 2020 National Inpatient Survey. Adults with diabetes and CDI were categorized into groups with and without DKA. Hospitalization characteristics, comorbidities, and clinical outcomes were compared. Primary outcomes included mortality, length of stay, and total hospital charges. Secondary outcomes included CDI complications. Multivariate logistic regression analysis was conducted, with P values ≤ 0.05 considered statistically significant. Results Among 494,664 diabetic patients with CDI, 6130 had DKA. Patients with DKA had significantly higher total hospital charges ($194,824 vs $103,740, P < 0.001) and longer length of stay (10.14 vs 6.04 days, P < 0.001). After adjusting for confounders, DKA patients had increased odds of mortality (adjusted odds ratio [aOR] 2.07), sepsis (aOR 1.40), septic shock (aOR 1.76), cardiac arrest (aOR 3.24), vasopressor use (aOR 2.01), and mechanical ventilation (aOR 1.96) (all P < 0.001). Conclusion The presence of DKA significantly elevates hospital burden and CDI complications in diabetic patients. These findings underscore the need for close monitoring and aggressive management of DKA in patients with concurrent CDI to improve outcomes.