Risk Of DKA Research Articles

Inpatient case characteristics of SGLT2 inhibitor-associated diabetic ketoacidosis: a retrospective study

ObjectivesDiabetic ketoacidosis (DKA) is a serious complication in patients treated with sodium-glucose co-transporter 2 inhibitors (SGLT2i). The aim of this study was to investigate the relationship between SGLT2i and the...

Predictors of the clinical severity of T1DM presentation at diagnosis in children and adolescents with type 1 diabetes mellitus (T1DM)

PurposeWe aimed to assess factors associated with the presence and severity of ketoacidosis (DKA) at pediatric type 1 diabetes (T1DM) diagnosis, in relation to pancreatic, associated and familial autoimmunity.MethodsAntibodies against pancreatic beta-cells, organ specific autoantibodies (thyroid, celiac, and parietal) and family history of autoimmunity were retrospectively evaluated in 116 T1DM patients aged 11.9 ± 4.6 (mean ± SD) years, with disease duration 7.62 ± 3.67 years (mean ± SD).ResultsMost patients (67.2%) presented with DKA at diagnosis. Younger children (< 2 years) had tenfold risk of DKA, compared to older children (12.1–15 years) (OR = 10.8, 95% CI: 1.0–116.9, P = 0.05). Fasting c-peptide levels were lower in the DKA group (OR = 0.26, 95% CI = 0.07–0.89, P = 0.033). The number of anti-pancreatic antibodies at disease onset did not show any significant correlations with the presence (p = 0.889) or severity of DKA (p = 0.863). All patients with multiple autoimmunity (> 2 autoimmune diseases plus T1DM) presented with DKA. Familial autoimmunity acted protectively against DKA manifestation (OR = 0.40, 95% CI = 0.16–1.0, P = 0.051).ConclusionsAmong newly diagnosed T1DM patients, 67.2% presented with DKA. Younger age, lower c-peptide and the presence of associated autoimmunity were predictive factors of the presence and severity of DKA at diagnosis. High degree of suspicion, due to family history, may prevent DKA development and severity.

THU247 Characterizing Inpatient Cases Of DKA Precipitated By SGLT2 Inhibitor Use

Abstract Disclosure: A. Aslamy: None. R. Nazemi: Speaker; Self; Eli Lilly &amp; Company, AstraZeneca. C. Tseng: None. S. Kim: None. R. Gianchandani: None. Background: SGLT2 inhibitors are a unique class of anti-hyperglycemic medications that can increase the risk of DKA in patients with diabetes (1). The overall incidence of DKA precipitated by SGLT2 inhibitor use is estimated to be 0.1%, however, this is likely higher in practice with increasing usage of these medications for treatment of heart failure and renal dysfunction. Herein, we characterize inpatient admissions with SGLT2 inhibitor induced DKA to further understand associated risk factors. Clinical Case: Euglycemic and hyperglycemic DKA cases (n=7) over a four-month period were identified, all of whom had been on SGLT2 inhibitors for an average of 8.5 (± 5.4) months prior to presentation. Six patients had T2D and one patient had known T1D. The average patient age was 69 (±8) years. The average A1c was 9.2% (±1.9%). Patients on dapagliflozin (n=3) had significantly higher A1c on admission compared to those on empagliflozin (n=4) (p=0.017). Average glucose on presentation of the six T2D patients was 206.5 (± 55.61) mg/dL (euglycemic DKA range) while the T1D patient presented with glucose of 605 mg/dL. All seven patients had elevated anion gap (mean 25.5 ± 7.2mEq/L), low bicarbonate (mean 8.9 ± 4.1 mmol/L), pH less than 7.4, and evidence of either ketonemia or ketonuria. Five out of the seven cases had a concurrent infection, and the remaining two cases were readmissions after recent cardiac surgery. All patients were treated with intravenous/subcutaneous insulin and intravenous dextrose with resolution of DKA within 24 hours. SGLT2 inhibitors were immediately discontinued. Average length of stay was 9 (±6) days, and was higher in the postcardiac surgery patients. Notably, the type of SGLT2 inhibitor (dapagliflozin vs. empagliflozin), age, sex, A1c on presentation, number of comorbidities, presence of infection, prior insulin usage, duration of diabetes, and duration of SGLT2 use had no significant effect on length of stay. Conclusion: Clinical characteristics of SGLT2 inhibitor induced DKA cohort were older age, uncontrolled diabetes (A1c &amp;gt;7), and concurrent infections or recent major surgery. Resolution of DKA was quick and length of stay longer for major surgery. When placed on SGLT2 inhibitors, diabetes patients should be warned of these potential clinical scenarios that can increase their risk of DKA. Reference: (1) Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: Analysis of FAERS data. Diabetes Metab Res Rev. 2017 Nov; 33 Presentation: Thursday, June 15, 2023

1147-P: Disparities in Insulin Pump and CGM Use in Youth with Type 1 Diabetes

Youth with T1D of underrepresented race/ethnicity (URE) have lower pump/CGM use, higher A1c, and greater DKA risk; however, the correlation of social determinants of health (SDoH) and neighborhood-level factors to pump/CGM use and clinical outcomes are unknown. In this study, multivariable models were used to evaluate the association of race/ethnicity, SDoH factors, and area deprivation index (ADI, range 1-10 with 10 being most deprived neighborhood) with pump/CGM use, A1c, and DKA in 1,461 T1D youth (50% F, age 12.8 ± 3.6 yrs, A1c 8.7 ± 2.1%, 52% pump, 70% CGM) seen over a 1-yr period. Youth were less likely to use a pump if they were Black or Hispanic, had Medicaid or were uninsured, received government assistance (i.e., SSI, Temporary Assistance for Needy Families (TANF), WIC, SNAP), or lived in a higher ADI neighborhood. Youth were less likely to use CGM if they were Black or Hispanic, had Medicaid or were uninsured, or lived in a higher ADI neighborhood. Youth had higher DKA risk in the past year if they lived in a higher ADI neighborhood or had government assistance; however, pump and CGM use were associated with lower DKA risk (Figure 1). For every 1 unit increase in ADI, A1c increased by 0.09 (95% CI: 0.05, 0.13). A1c was 0.62 lower (95% CI: -0.82, -0.42) in pump users vs. not and 0.78 lower (95% CI: -0.99, -0.56) in CGM users vs. not. Advocacy efforts and QI projects promoting technology use in T1D youth of URE and lower SES may improve A1c and decrease risk of DKA. Disclosure E.R.Crain: None. R.Ramphul: None. A.Butler: None. X.C.Huang: None. C.G.Minard: None. M.J.Redondo: None. D.Desalvo: Consultant; Dexcom, Inc., Research Support; Insulet Corporation.

Safety outcomes of sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes and other risk factors for cardiovascular disease: a systematic review and meta-analysis.

An electronic database search was conducted for randomized control trials comparing SGLT2-Is to placebo in patients with a high risk of cardiac disease or heart failure. Data were pooled for outcomes using random-effect models. The odds ratio (OR) and 95% confidence interval (CI) were used to compare eight safety outcomes between the two groups. The analysis included ten studies with 71 553 participants, among whom 39 053 received SGLT2-Is; 28 809 were male and 15 655 were female (mean age, 65.2 years). The mean follow-up period was 2.3 years with the range being 0.8-4.2 years. The SGLT2-Is group had a significant reduction in AKI (OR = 0.8;95% CI 0.74-0.90) and serious adverse effects (OR = 0.9; 95% CI 0.83-0.96) as compared to placebo. No difference was found in fracture (OR = 1.1; 95% CI 0.91-1.24), amputation (OR = 1.1; 95% CI 1.00-1.29), hypoglycemia (OR 0.98;95% CI 0.83-1.15), and UTI (OR = 1.1; 95% CI 1.00-1.22). In contrast, DKA (OR = 2.4; 95% CI 1.65-3.60) and volume depletion (OR = 1.2; 95% CI 1.07-1.41) were higher in SGLT2-Is group. The benefits of SLGT2-Is outweigh the risk of adverse events. They may reduce the risk of AKI but are associated with an increased risk of DKA and volume depletion. Further studies are warranted to monitor a wider range of safety outcomes of SGLT2-Is.

Disordered Eating Behaviors and Insulin Restriction in Saudi Adolescents and Young Adults with Type 1 Diabetes

Background and Objectives: The prevalence of disordered eating behaviors (DEBs) in type 1 diabetes (T1D) has been studied globally; however, data from Saudi Arabia and Arab-speaking countries are scarce. This study aimed to measure the prevalence of DEBs and associated clinical characteristics in adolescents and young adults with T1D, and the impact of DEBs on glycemic parameters. Materials and Methods: A total of 265 adolescents and young adults with T1D (aged 12-25 years) were recruited randomly from the registry at the Jazan Endocrinology and Diabetes Center, Saudi Arabia. Participants completed the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire. Other measures included hemoglobin A1c (HbA1c) in addition to sociodemographic, anthropometric, and clinical data. Results: The prevalence of DEBs among T1D was 27.2%. Females (32.5%) had a higher proportion of DEBs than males (18.6%) (p = 0.01). About 27% of the participants reported insulin restriction. A history of hospital admission in the previous 6 months due to DKA and frequent hypoglycemia was more frequently reported in T1D participants with DEBs compared to those without (p = 0.03). Participants with DEBs had higher HbA1c and higher BMI compared to those without DEBs. Conclusions: Adolescents and young adults with T1D with disordered eating and insulin restriction have higher glycated hemoglobin, and are at higher risk of DKA. Routine screening for DEBs should be an essential element in diabetes care, especially among highly vulnerable groups.

PSUN196 Outcomes following SGLT-2 inhibitor use in 99 patients with type 1 diabetes: A single-centre, retrospective, chart-review study

Abstract Introduction Despite the numerous benefits seen with the use of SGLT-2 inhibitors in patients with T1DM, the drug class has failed approval for this indication in both the US and Australia, largely due to the increased risk of ketosis and DKA. Resultantly there is limited real-world data for its use in this patient population. Methods We completed a retrospective medical record review of 99 patients with T1DM treated with an SGLT-2 inhibitor within a single outpatient clinic between 2014 to 2021. Our primary objective was to review the change in Hba1c and weight, as well as incidence of DKA, with secondary objectives to review the reduction in insulin dose, and reasons for cessation. Results Baseline characteristics demonstrated a female predominant population (63%) with a median BMI of 30kg/m2. Around half of our patients were on concurrent CSII therapy (53%) We observed an improvement in Hba1c in 72% of our patients, with a median decrease of 0.3% (P=0.001). 80% of patients noted a decrease in weight, with a median reduction of 4.2kg (P=0.10). Five patients developed DKA requiring hospitalisation, and the most common cause for SGLT-2i cessation was genital tract infection. The insulin requirement was noted to decrease by an median of 6.6 units (P=0.04). Conclusion SGLT-2 inhibitor class medications have a valuable role in the treatment of certain patients with T1DM. Our study is one of only a handful of real-life data sets, and unique in the number of patients involved. Future areas for review involve evaluating the effect of risk mitigation measures on the incidence of DKA. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP244 SGLT2 Inhibitor-Induced Euglycemic DKA and its Challenges

Abstract Introduction Sodium-glucose cotransporter type 2 inhibitors (SGLT2-i) have proven to be a gamechanger for patients with diabetes, cardiovascular, and renal disease. However, this class of medications confers an increased risk for adverse side effects such as genitourinary infections and, rarely, euglycemic diabetic ketoacidosis (EDKA). Studies have shown that the risk of euglycemic DKA from SGLT2 inhibitors increase sevenfold in patients with type 2 diabetes mellitus (T2DM) with an overall incidence of approximately 0.1%. These side effects need to be taken into consideration when prescribing this type of therapy. Case Description Case of a 61-year-old male, with hypertension, type 2 diabetes mellitus on glargine, insulin lispro and empagliflozin, adherent to his regimen. Also, patient had a history of CAD s/p PCI (2015), and urethral stricture with self-catheterization who presented to the ED complaining of genital pain of 4 days evolution. Patient had been treated at home with clindamycin without improvement of symptoms. Upon evaluation at ED, laboratories were remarkable for WBC: 25.90, glucose: 144mg/dL, sodium: 134mmol/L, potassium: 5.3mmol/L, CO2: 10mmol/L, ketones: large. Arterial blood gases with metabolic acidosis and anion gap: 26.3. [LAG1] Glycated hemoglobin was 6.8%. Urinalysis was significant for glucosuria 1000 mg/dL, SG 1. 036, 30 mg/dL of protein, negative for nitrites and leukocyte esterase, and few bacteria. Blood glucose levels remained between 145-194 the first 24 hours after admission. Urology service performed a penile exploration with the finding of bilateral corpus cavernosum abscesses that were drained and cultured. Patient was diagnosed with EDKA and started therapy with IV insulin infusion as per DKA protocol, however 10% dextrose infusion was required to continue insulin IV infusion until ketoacidosis resolution. Broad spectrum IV antibiotics were initiated. However, his clinical condition deteriorated and developed respiratory failure requiring mechanical ventilation. After 36 hours of insulin infusion, IV antibiotics and fluids, his anion gap normalized. Abscess and blood cultures reported Candida Glabrata. Antifungal therapy was started and after seven days, the patient's clinical condition improved with resolution of his sepsis and DKA, and was successfully extubated. Patient was discharged to a rehabilitation facility. Conclusion EDKA presents a diagnostic and treatment challenge. It should be suspected in patients with metabolic acidosis, ketonemia and under treatment with a SGLT2-i, even in the absence of hyperglycemia. Prompt treatment initiation with IV insulin infusion along with IV dextrose is important for resolution of DKA. Five-percent dextrose solution should be started and titrated as needed, but if ketoacidosis does not resolve, 10% dextrose can be considered to maintain the insulin infusion. Prescribing this class of hypoglycemic medication should be avoided in those who are clearly at high risk of this well-known complications. Patient education regarding early recognition and to seek early medical evaluation are essential. [LAG1]Anadir unidades Presentation: No date and time listed

ODP195 EUGLYCEMIC DIABETIC KETOACIDOSIS AFTER BARIATRIC SURGERY IN ASSOCIATION WITH USE OF SGLT2I.

Abstract Introduction The risk of euglycemic DKA (EuDKA) is well-known with use of SGLT2i. We present two cases where EuDKA occurred despite discontinuing SGLT2i one week prior to bariatric surgery. Case 1 A 43 year old male with type II diabetes mellitus and obesity class III presented with nausea and vomiting two weeks following gastric sleeve surgery. Preoperatively, the patient was taking glargine, lispro, empagliflozin and metformin. Empagliflozin was discontinued seven days before surgery. After surgery, patient was discharged on empagliflozin only. Labs showed blood glucose 266 mg/dl, anion gap (AG) 32 mmol/L, HCO3 11 mmol/L and betahydroxybutyrate &amp;gt; 6 mmol/L. He was admitted to the ICU and managed according to the guidelines for DKA. On discharge, his empagliflozin was discontinued. Case 2 31 year old female with type II diabetes, obesity class III developed nausea and vomiting a day after Roux-en-Y gastric bypass surgery. Preoperatively patient was taking glargine, metformin, dulaglutide and empagliflozin. Patient discontinued empagliflozin seven days before surgery. Labs showed glucose 232 mg/dl, AG 23 mmol/L, HCO3 6 mmol/L and betahydroxybutyrate 6.96 mmol/L. She was admitted to the ICU and managed according to the guidelines for DKA. Empagliflozin was discontinued on discharge. Discussion In case 1, EuDKA occurred two weeks postoperatively. In case 2, EuDKA occurred one day postoperatively. In both cases the SGLT2i was discontinued seven days before the surgery. The use of SGLT2i is a cause of EuDKA. The pathophysiology of EuDKA is not clear but thought to be related to a relative carbohydrate deficit, increased glucosuria and low insulin levels. Additionally, SGLT2i may directly stimulate glucagon release leading to increased lipolysis. There have been number of case reports suggestive of EuDKA after gastric bypass surgery in association with use of SGLT2i. Bariatric surgery causes changes in incretin pathways which in turn changes insulin: glucagon ratio and responses to blood glucose in immediate post-operative period. Additionally, preoperatively these patients are on water or ketogenic diet causing ketogenic state. However, in our cases the SGLT2i were discontinued seven days before surgery. It is not known if the use of SGLT2i therapy in the preoperative period might pose an increased risk of EuDKA due to changes in incretin based pathways associated with weight loss surgery and SGLT2i. Conclusion It is important to recognize that use of SGLT2i in setting of bariatric surgery perioperatively increases the risk of EuDKA. Our cases suggest two things. One it may be necessary to discontinue SGLT2i more than seven days before bariatric surgery and second initiating SGLT2i for patients with history of bariatric surgery should be considered an additional risk factor for EuDKA due to permanent changes in incretin based pathways and other mechanisms. Presentation: No date and time listed

PSUN263 Diagnosis of Latent Autoimmune Diabetes of Adulthood Unveiled After Initiation of an SGLT2 Inhibitor

Abstract SGLT2-inhibitors have revolutionized treatment for Type II diabetes (T2DM) due to their numerous benefits including improved glycemic control, cardioprotective properties, reduction of high blood pressure, and mitigation of disease progression in CKD.ew studies have investigated the benefits of this medication class on patients with Type 1 DM (T1DM). Herein we describe a case in which the diagnosis of latent autoimmune diabetes of adulthood (LADA) was unmasked following the use of an SGLT2-inhibitor. A 56-year-old female with a history of T2DM diagnosed 10 years ago presented to the endocrine clinic for management of her poorly controlled diabetes. Her medications then included insulin detemir, insulin lispro, metformin, and repaglinide, but she still had an HbA1c of 11.3% (n&amp;lt;5.7%). She was tried on glipizide early in her disease course but it was discontinued due to fluid retention. She had a sedentary lifestyle with a BMI of 31.27 kg/m2. She was requiring increased doses of insulin over time with minimal improvement in her HbA1c. Two years later she was started on liraglutide with increasing dosages. Her HbA1c continued to decrease down to 8.7% and her BMI had decreased to 26.83 kg/m2. Over the next year, her HbA1c began to again increase up to 9.8%. At this time canagliflozin was added to her medication regimen. She responded very well to this medication initially with a drop in her HbA1c to 7.5% and a decrease in her BMI to 24.01 kg/m2. Unfortunately, one year after initiation of the SGLT2-inhibitor she was hospitalized for DKA and pancreatitis. At this time all her medications, except for insulin and metformin, were discontinued. A GAD65 antibody (&amp;gt;250 IU/mL; n&amp;lt;5.0 IU/mL) and c-peptide (&amp;lt;0.1 ng/mL; n = 1.1-4.4 ng/mL) levels were checked at this time which revealed the diagnosis of LADA approximately 16 years after her initial diagnosis of T2DM. She was transitioned to an insulin pump and managed according to protocol. SGLT2 inhibitors have been studied as an adjuvant treatment with insulin for T1DM due to their ability to increase urinary glucose excretion but are currently not approved for T1DM. Despite their recorded benefits, they have also been shown to significantly increase the risk of DKA when used in patients with T1DM. Our patient, who was mistakenly treated as T2DM for almost two decades, was diagnosed with LADA after initiation of an SGLT2 inhibitor led to hospitalization for DKA. Further research is needed to assess the safety of SGLT2 inhibitors in T1DM, and caution must be taken when prescribing this medication to patients who may have underlying LADA. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

Clinical and biochemical characteristics of diabetic ketoacidosis in adults with type 1 or type 2 diabetes at a tertiary hospital in the United Arab Emirates.

Diabetes ketoacidosis (DKA) is a well-known acute complication of diabetes. This study aims to describe the sociodemographic, clinical, and biochemical characteristics of adult patients with different diabetes types and DKA severities attending a tertiary hospital in the UAE. We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 220 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2020.Results: The average age was 30.6 ± 16.6 years of whom 54.5% were women, 77.7% were UAE nationals and 77.9% were Type 1 diabetes (T1DM). 12.7% were newly diagnosed with diabetes. Treatment noncompliance (31.4%), and infection (26.4%) were the main precipitating factors. Most patients presented with moderate DKA (50.9%). Compared to T1DM, patients with Type 2 diabetes (T2DM) were older (53.6 vs 23.9 years, p < 0.001), had longer hospital stay (12.1 days vs 4.1 days, p < 0.001), had more complications (52.1%, vs 18.9% p <0.001), and a higher mortality rate (6.3% vs 0.6%, p = 0.035). Patients with severe DKA had a shorter diabetes duration compared to mild and moderate DKA (5.7 vs 11.0 vs 11.7 years, respectively, p = 0.007), while complications were significantly lower in the mild group compared to both the moderate and severe groups (11.6% vs 32.1% vs 33.3%, respectively). The risk of DKA is higher for patients with T1DM than for those with T2DM. The clinical characteristics and outcomes of patients with T2DM differ from those with T1DM highlighting the importance of educating all patients about DKA.

835-P: The Hepatoselective Glucokinase Activator (GKA) TTP399 Does Not Increase Risk of Ketoacidosis in Type 1 Diabetes (T1D)

Identification of adjunctive, oral pharmacotherapies to treat T1D has been limited by risk of DKA. TTP399, an oral hepatoselective GKA, significantly improves glycemia in individuals with T1D compared to placebo. This double-blind, randomized, placebo-controlled, Phase 1 mechanistic study examined whether TTP399 decreases ketogenesis during insulin withdrawal. Individuals with T1D (n=23) using insulin pump therapy were randomized to TTP399 or placebo for 7-days after which an insulin withdrawal test (IWT) was performed. Insulin pumps were disconnected for up to hours to induce ketogenesis. TTP399 significantly reduced fasting glucose (-27.6 vs. -4.4 mg/dL, p = 0.03) . During the treatment period, adverse events were fewer in TTP399-treated subjects. No hypoglycemic events &amp;lt;54mg/dL were observed in the TTP399 group compared with 2 subjects in the placebo group. Following insulin withdrawal, no significant differences in mean duration of IWT or beta-hydroxybutyrate (BOHB) at termination were observed between treatment groups (Figure 1A) . Serum bicarbonate was numerically higher and urine acetoacetate was qualitatively lower in TTP399-treated subjects (Figure 1A) . No patients on TTP399 met prespecified criteria for DKA while 43% of subjects on placebo did (Figure 1B, p = 0.03) . These data suggest that TTP399 treatment improves glucose control with no increased risk of DKA. Disclosure K.Klein: None. S.C.Boeder: Consultant; Cecelia Health, Research Support; Dexcom, Inc., Lilly. J.L.Freeman: Employee; vTv Therapeutics, Stock/Shareholder; vTv Therapeutics. S.Madduri: None. E.R.Giovannetti: None. C.Valcarce: Employee; vTv Therapeutics. J.B.Buse: Consultant; Alkahest, Anji, AstraZeneca, Boehringer Ingelheim International GmbH, Cirius Therapeutics, Inc., Eli Lilly and Company, Fortress biotech, GentiBio, Glycadia, Glyscend, Janssen Pharmaceuticals, Inc., Mellitus Health, Moderna, Inc., Pendulum Therapeutics, Praetego, LLC, Stability Health, Valo, Zealand Pharma A/S, Other Relationship; Adocia, AstraZeneca, Eli Lilly and Company, Intarcia Therapeutics, Inc., MannKind Corporation, Novo Nordisk, Sanofi, Senseonics, vTv Therapeutics, Research Support; AstraZeneca, Dexcom, Inc., Eli Lilly and Company, Novo Nordisk, vTv Therapeutics, Stock/Shareholder; Glyscend, Mellitus Health, Pendulum Therapeutics, PhaseBio Pharmaceuticals, Inc., Praetego, LLC, Stability Health. J.Pettus: Advisory Panel; Lilly, MannKind Corporation, Novo Nordisk, Sanofi, Consultant; Carmot Therapeutics, Inc., Diasome. Funding JDRF international

1500-PUB: Characteristics of Inpatients with DKA and SGLT2i Use at a Tertiary Hospital

Background: SGLT-2 inhibitors (SGLT2i) have cardiovascular and renal benefits but pose an increased risk of DKA. The risk factors for developing DKA while on SLGT2i therapy have not been fully characterized. Methods: A retrospective, observational chart review was performed to include patients admitted to Houston Methodist in 20with DKA and SGLT2i use. DKA was confirmed using standard laboratories. Potential causes of DKA were categorized based on prior published associations. Results: Among the 61 patients with DKA, SGLT2i therapy was used at home but discontinued on admission in 46 (75%) , initiated during the hospitalization in 6 (10%) , and continued throughout the hospitalization in 9 (15%) . Potential causes of DKA were infections in 23 (38%) patients, gastrointestinal etiologies in 21 (34%) , NPO and/or perioperative status in 4 (7%) , acute cardiovascular events in 3 (5%) , and (16%) patients had no identifiable etiology. Conclusions: Among hospitalized patients with DKA and SGLT2i use, we observed poorly controlled diabetes mellitus, with infection and GI disease being the most common associations. This description could help inform strategies to guide safe use of SGLT2i therapy. Disclosure S.Williamson: None. M.B.Taha: None. T.R.Brown: None. S.Hebert: None. K.Patel: None. V.J.Narcisse, iii: None. A.R.Sadhu: Advisory Panel; Abbott Diagnostics.

931-P: Characteristics and Outcomes of DKA Admissions Before and During COVID-Pandemic

Background: COVID-increases risk of DKA and poor outcomes in patients with diabetes. Methods: A retrospective review was conducted of 4,959 DKA admissions from 1/1/2019-12/31/2021 at our hospital system. EHR data was collected on consecutive admissions coded with DKA for clinical characteristics, hospital outcomes of length of stay (LOS) , 30day readmission (30d RADM) and mortality. Data was analyzed for differences stratified by year 20vs. 2020 and 2021, and by COVID-infection. Results: Compared to 2019, patients in 2020 were older, more Hispanic and had CHF. Compared to 2019, patients in 2021 had less HTN and kidney disease but similar rates of CHF; Table 1. Mortality and LOS were higher for 2020 and 2021 while 30d RADM was lower; Table 2. Conclusion: Despite advancements in COVID-treatments, DKA patients have progressively poorer outcomes. Disclosure A.Kansara: None. D.T.Nguyen: None. S.L.Yarlagadda: None. E.Graviss: None. A.R.Sadhu: Advisory Panel; Abbott Diagnostics.

The Pathophysiology and Management of Diabetic Ketoacidosis in COVID-19 Patients: a Literature Review.

Diabetic individuals are considered a vulnerable population during the COVID-19 Pandemic, and several studies noted worse outcomes, including death, among those who get infected. Diabetic emergencies, such as ketoacidosis (DKA), are common and potentially life-threatening conditions in uncontrolled patients. While the pathophysiological background of the relationship between COVID-19 and DKA is not fully understood, early reports available so far indicate that patients with pre-existing diabetes who get infected with the SARS-CoV 2 virus are at higher risk of DKA. It was also suggested that DKA is a poor prognostic sign for infected patients, these being at higher risk of developing worse forms of COVID-19 disease and having high mortality. Therefore, healthcare personnel dealing with such patients face a considerable challenge, as the correct and safe emergency management of such cases is far from established. This article aimed to conduct a study that reviews the current published data available about patients with DKA and COVID-19.

Diabetic ketoacidosis and mortality in COVID-19 infection

Aim- Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients. Methods- Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19. Results- Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40–1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06–1.08) and need for pressors (HR 2.33, 95% CI 1.82–2.98). Glucocorticoid use was protective in patients with and without DKA. Conclusion- The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

917-P: Supervised Basal Insulin Injections Prevent Ketosis in Youth with Type 1 Diabetes (T1D)

Youth with T1D and high HbA1c are at higher risk of DKA. This study examined whether daily school-supervised basal insulin injections reduced the risk of morning ketosis in youth with high HbA1c. We hypothesized that glargine and degludec would reduce the risk of ketosis, and explored whether the prolonged action of degludec protects from ketosis after 2-4 days unsupervised injections. After a 2-4 week run-in, youth (10-18y) on injections with A1c ≥ 8.5% were randomized to supervised administration of either degludec or glargine for 4 months. School nurses observed daily fasting blood β-hydroxybutyrate (βHB) and glucose checks and basal insulin doses. During COVID closures, our research team is supervising procedures remotely. Twenty-four youth (mean age 14.4 ± 2.4 y, 67% F, HbA1c 11.6% ± 1.9%) were analyzed. Supervised injections of both basal insulins for 1-4 days progressively lowered the % participants with elevated βHB (Figure). The % of participants with elevated βHB after 2 days of unsupervised basal insulin tended to be greater in the glargine group. HbA1c did not change. None had DKA. In high risk youth with T1D, daily supervised insulin administration decreased the probability of elevated ketone levels the following school day, regardless of insulin type. A larger sample is needed to determine if degludec’s longer action profile offers additional protection from ketosis during days off from school. Disclosure L. M. Nally: None. M. A. Van name: None. O. K. Sosnoski: None. J. Sherr: Advisory Panel; Self; Cecelia Health, Insulet Corporation, Medtronic, Consultant; Self; Insulet Corporation, Lexicon Pharmaceuticals, Inc., Lilly Diabetes, Medtronic, Research Support; Self; Dexcom, Inc., Insulet Corporation, Medtronic, Speaker’s Bureau; Self; Lilly Diabetes. E. M. Tichy: None. K. Weyman: None. A. Steffen: None. S. Mccollum: None. V. Shabanova: None. W. V. Tamborlane: Consultant; Self; Medtronic, Sanofi, Other Relationship; Self; Tolerion, Inc. Funding National Institutes of Health (K12DK094714); Novo Nordisk

ABCD Conference 2020 Abstracts

Background: In response to the COVID-19 pandemic, UHL rapidly implemented a daily (Monday-Friday) VIDS running from 23/03/20 to 03/08/20. All inpatients with diabetes (including COVID-19 positive) were reviewed virtually. During the pandemic, the numbers of inpatients with diabetes fell from on average >300 (pre-pandemic) to approximately 200 each day. The peak of UHL inpatients with COVID-19 (April 2020) was 204 patients. Aims: The aims of the study were as follows: (1) to review all patients with diabetes ±COVID-19;(2) to minimise exposure of staff to COVID-19;(3) to preserve PPE for frontline staff;and (4) evidence safe levels of care. Results: All patients: % CBG 25.0 mmol/L was 0.9, 0.8 and 0.8 pre, during and post VIDs. Patients with CFS 5 or above: % CBG 25.0 mmol/L was 1.2, 0.7 and 0.8 pre, during and post VIDs. NaDIA harms: no rise in hypo harms during VIDs. Two cases of in-hospital DKA were identified by VIDS team (3 DKA harms reported), one case: COVID-19 positive taking SGLT2i. Discussion: Introduction of a VIDS did not lead to detrimental outcomes in terms of in-hospital harms. A small increase in % CBG <2.9 mmol/L for all patients was not associated with a rise in NaDIA hypo harms. If we need to reinstate a VIDS during a second COVID-19 wave, we can be reassured re safety and should focus on minimising risk of hypoglycaemia, appropriate targets for individual patients (eg, older/frail/EoL patients) and risk of DKA with COVID-19/SGLT2i and national guidance for management of inpatients with diabetes and COVID-19.

Diabetic Ketoacidosis and Mortality in COVID-19 Infection

Background: Hyperglycemic patients with or without a history of diabetes have increased morbidity and mortality from COVID-19. Published case reports describe patients with COVID-19 and simultaneous presentation of diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in patients hospitalized with COVID-19.Methods: Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19.Findings: Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA. Ninety-four percent of patients with incident DKA had a history of type 2 diabetes, while 5.7% patients had no prior diagnosis of diabetes. Patients with compared to without DKA had increased hospital length of stay and in-patient mortality. Each unit of higher HbA1c predicted a 47% increased risk of incident DKA (HR 1.47, 95% CI 1.40-1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06 - 1.08) and need for pressors (HR 2.33, 95% CI 1.82-2.98). An interaction between use of glucocorticoids and older age and pressor use indicated a protective effect of glucocorticoid use with both increasing age and for patients on pressors.Interpretation: The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and severity of COVID-19 disease. Improved outpatient treatment of diabetes may prevent the development of DKA in patients with COVID-19.Funding Statement: None.Declaration of Interests: JSS, MBB, DJM, JZ, PK, SM, MTY and UBP have no disclosures. TLN: AmgenEthics Approval Statement: This study protocol was approved by the Institutional Review Board of Columbia University Irving Medical Center and the requirement for informed consent was waived.