Severe Diabetic Ketoacidosis Research Articles

Precipitating Factors and Outcome of Diabetic Ketoacidosis among Children and Adolescents with Type-1 Diabetes Mellitus.

To determine the precipitating factors and outcomes of diabetic ketoacidosis (DKA) among patients with type 1 diabetes mellitus. An analytical study. Place and Duration of the Study: Department of Paediatrics, National Institute of Child Health, Karachi, Pakistan, from July to December 2022. Children of either gender aged up to 18 years and presenting with DKA with a known diagnosis of type-1 diabetes were enrolled. Demographic, clinical, and anthropometric characteristics of all children were noted. Laboratory investigations were sent to the institutional laboratory. Presenting features, precipitating factors, severity of DKA, and outcomes noted. Among 131 children, 101 (77.1%) were girls. The socio-economic status of 75 (57.3%) patients was the lower middle. Celiac disease was the commonest associated disease noted in 23 (17.6%) patients. A total of 123 (93.9%) children were using basal plus bolus types. Adherence to diabetes-related drug therapy was seen in 105 (80.2%) patients. At the time of presentation, vomiting, fever, abdominal pain, and respiratory distress were the most frequent presenting features reported in 77 (58.8%), 67 (51.1%), 42 (32.1%), and 34 (26.0%) patients, respectively. The most common precipitating factors for DKA were infection/illness (n=90, 68.7%) and missed insulin dose (n=16, 12.2%); no cause was identified in 25 (19.1%) patients. The mean duration of hospital stay was 5.25±2.4 days. Four patients could not survive. The most common precipitating factor for the current episode of DKA were infection or illness, or missed insulin dose. Vomiting, fever, abdominal pain, and respiratory distress were the most frequent presenting features. In-hospital mortality was found to be 3% in DKA patients. Diabetic ketoacidosis, Type-1 diabetes mellitus, Insulin, Vomiting, Abdominal pain.

Real-world adherence to toxicity management guidelines for immune checkpoint inhibitor-induced diabetes mellitus.

Immune checkpoint inhibitors(ICIs) have improved survival and are increasingly used for cancer. However, ICIs use may be limited by immune-related adverse events (irAEs), such as ICI-induced diabetes mellitus(ICI-DM). The objective of the present study was to characterize ICI-DM patients and real-world adherence to guidelines. The present study was a retrospective review of electronic records of ICI-DM patients at the First Affiliated Hospital of Nanjing Medical University between July 2018 and October 2022. 34.8% (8/23)patients monitored blood glucose in every treatment cycle. The proportion of patients with severe diabetic ketoacidosis(DKA) was lower in the tight glycemic monitoring group than the non-tight glycemic monitoring group (16.7% vs. 55.6%, p = 0.049). 78.3%(18/23) patients with hyperglycemia visited a non-endocrinologist first, but 95.7% of patients were then referred to an endocrinologist. Twenty patients were tested for distinguishing the etiology of hyperglycemia and 20% patients with positive glutamic acid decarboxylase antibody(GADA), 55% with C-peptide <3.33pmol/L. High screening rates for other ICI-induced endocrinopathies were observed and half of the patients with ICI-DM developed other endocrine gland irAEs, with the most common being thyroiditis. Moreover, five patients developed non-endocrine serious adverse events(SAEs). Twelve (52.2%) patients were withdrawn from ICI due to ICI-DM. The time to progression of tumor in ICI-DM patients in the continue and interruption group was longer than in the withdrawal group (333.5 ± 82.5 days vs. 183.1 ± 62.4 days, p = 0.161). Only 17.4% of ICI-DM patients were completely managed according to guidelines. Thus, the present study proposed a screening, diagnosis, and management algorithm for ICI-DM in real-world practice. The present study reported the largest number of ICI-DM cases described in a single institute, providing insight into real-world ICI-DM management guideline adherence and highlighting the clinical challenges in ICI-DM management.

Clinical Use of Continuous Glucose Monitoring in Critically Ill Pediatric Patients with Diabetic Ketoacidosis.

Background: The use of continuous glucose monitoring (CGM) in pediatric patients with diabetic ketoacidosis (DKA) remains investigational, and data on its accuracy in pediatric intensive care units (PICU) are limited. This study evaluated the accuracy of three CGM devices in pediatric patients with DKA in the PICU. Methods: We compared 399 matched pairs of CGM and point-of-care capillary glucose (POC) values and grouped patients based on whether they changed their CGM sensor during their PICU stay. Results: Eighteen patients with a mean age of 10.98 ± 4.20 years were included, with three patients in the sensor change group. The overall mean absolute relative difference (MARD) was 13.02%. The Medtronic Guardian Sensor 3 (n = 331), Dexcom G6 (n = 41), and Abbott FreeStyle Libre 1 (n = 27) showed MARD values of 13.40%, 11.12%, and 11.33%, respectively. The surveillance error grid (SEG), Bland-Altman plot, and Pearson's correlation coefficient demonstrated satisfactory clinical accuracy of the CGM devices (SEG zones A and B, 98.5%; mean difference, 15.5 mg/dL; Pearson's correlation coefficient [r2], 0.76, P < 0.0001). MARD was significantly lower in subjects who did not experience a sensor change (11.74% vs. 17.31%, P = 0.048). Also, a statistically significant negative correlation was found between serum bicarbonate levels and POC-CGM values (r = -0.34, P < 0.001). Conclusions: The severity of DKA has a major effect on reducing the accuracy of the CGM, especially during the first several days in the intensive care unit. The reduced accuracy appears to be related to acidosis, as reflected in the serum bicarbonate levels.

A Study of Hypomagnesemia in Patients Admitted to the ICU.

Introduction After potassium, magnesium (Mg2+) is the most prevalent cation found intracellularly in the human body. The maintenance of excitability by Mg2+ and other cations is crucial for the neuromuscular junction to operate normally. Magnesium shortages are frequently overlooked compared to other electrolyte disorders such as hyponatremia, hypokalemia, and hypocalcemia. The present study aimed to study the factors and effects of hypomagnesemia amongintensive care unit (ICU) patients who are critically ill at atertiary care hospital. Methods This is a prospective observational study done among the patients who got admittedto the Medical ICUat Maharajahs Institute of Medical Sciences (MIMS), Nellimarla, Vizianagaram, from January 2020 to June 2021. A total of 100 patients were included in the study, of which 50 were cases and 50 were controls. The cases are those patients admitted to the medical ICU with critical illness and hypomagnesemia, and the controls are selected from those patients admitted with critical illness to the medical ICU with normal magnesium levels. Patients with severe infections, including sepsis, respiratory failure, cardiac failure,renal failure, cerebrovascular accidents (CVA), poisonings, and diabetic ketoacidosis (DKA), were included in the study. Patients who were treated with magnesium before admission to our ICU were excluded from this study. Serum magnesium was tested within24 hours of admission and is correlated with the outcomes of the patients in terms of APACHE II score, length of ICU stay, and requirementand duration ofventilatory support. Results Out of a total of 50 cases, 29 (58%) are of males. The mean age of cases was57.6 ∓ 8.2 years. Most cases were admitted due to organ failure (30%), followed by sepsis (26%) and poisoning (22%). The mean magnesium levels were 1.19 mg/dL among the cases, which was significantly lower when compared to the control group (2.16 mg/dL) (p-value= 0.01). The mean length of stay in the ICU was 6.12∓5.16 days in cases, whereas it was 5.28∓3.37 days in the control group (p-value = 0.33). 12% of cases needed non-invasive ventilation (NIV) when compared to 8% of controls (p-value= 0.50). 48% of the cases needed invasive ventilator support when compared to 28% in the control group (p-value= 0.03). The duration of invasive ventilation was higher among the cases (mean = 10 ∓3-17 days) compared to the controls(mean = 3 ∓2-4 days);p-value = 0.001.Mortality was higher in the case groupat 28% (14) and was 10% (5) in the control group (p-value = 0.02). Conclusion The need for invasive ventilation and duration of invasive ventilation were significantly higher among thepatients with hypomagnesemia compared to the patients with normal magnesium levels (p-value<0.05).Mortality was higher in the cases than in the controls (p-value<0.05).

Diabetic Ketoacidosis and Long-term Insulin Requirements in Youths with Newly Diagnosed Type 2 Diabetes During the SARS-CoV-2 Pandemic

ObjectiveSARS-CoV-2 infection increases the risk of diabetes and diabetic ketoacidosis (DKA) in both adults and children. We investigated the clinical course of new-onset type 2 diabetes in youth presenting with DKA during the COVID-19 pandemic. MethodsThis single-center retrospective cohort study included 148 subjects with obesity aged 10 to 21 years, admitted with DKA from January 2018 to January 2022. Groups were defined by the presence of DKA precipitant: any infection (n = 38, 26%), which included the SARS-CoV-2 (n = 10, 7%) and other infection (n = 28, 19%) groups, and no infection (n = 110, 74%). The primary outcome was insulin discontinuation within a 12-month follow-up. ResultsThe mean age was 14.9 years (IQR, 13.8-16.5), and age-adjusted body mass index (%) was 99.1 (IQR, 98.0-99.5) with 85.8% identifying as Black or Hispanic. There were no differences in DKA severity among groups. The incidence of DKA was higher during the pandemic (March 2020-January 2022, n = 117) than in the prepandemic period (January 2018-February 2020, n = 31). Within the first year after the acute DKA episode, 46 patients discontinued all insulin within 9 months (IQR, 4-14). Sixteen subjects restarted insulin 10 months (IQR, 6.5-11.0) after insulin discontinuation. Infection with SARS-CoV-2 at diagnosis was not associated with the likelihood (P =.57) or timing (P =.27) of discontinuing all insulin within 1 year, nor was having any infection. ConclusionThe incidence of DKA at the onset of type 2 diabetes was higher during the SARS-CoV-2 pandemic than in the prepandemic period. SARS-CoV-2 infection was not associated with DKA severity or insulin discontinuation within the first year of diagnosis in youth with new-onset type 2 diabetes and DKA.

Incidence of diabetic ketoacidosis does not differ in Ramadan compared to other months and seasons: results from a 6-year multicenter study

Background Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA. Methods We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons. Results Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25–45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons. Conclusions DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar.

Case report of empagliflozin-induced euglycemic diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a common metabolic emergency in diabetic patients encountered by emergency departments (EDs). Euglycemic diabetic ketoacidosis (EDKA) is a rare type of DKA characterized by normal to slightly elevated blood glucose levels. Possible causes of EDKA include fasting, pregnancy, and alcohol consumption. In this report, we are presenting a case of EDKA associated with the use of empagliflozin, an oral antihyperglycemic medication belonging to the sodium-glucose co-transporter 2 inhibitors (SGLT-2). The case is a 43-year-old diabetic male patient, who presented to the ED complaining of nausea, vomiting, and generalized weakness. Upon history taking, it was found that the patient started taking empagliflozin 10 days ago. Accordingly, appropriate diagnostic tests were requested, and the patient was found to have severe DKA despite normal to slightly elevated blood glucose results. A diagnosis of EDKA was confirmed, and the patient was successfully treated and discharged few days later. Many reports have linked the use of SGLT-2 inhibitors with an increased risk of developing DKA, especially EDKA. Although the management of DKA and EDKA is similar, it is more challenging to diagnose the latter. We have highlighted these challenges and the most common precipitating factors. Additionally, we highlighted the mechanism for developing EDKA and the appropriate diagnostic approach to follow with diabetic patients using SGLT-2 inhibitors.

A Comparison of Faster Insulin Aspart with Standard Insulin Aspart Using Hybrid Automated Insulin Delivery System in Active Children and Adolescents with Type 1 Diabetes: A Randomized Double-Blind Crossover Trial.

Objective: To evaluate the use of faster acting (FIA) and standard insulin aspart (SIA) with hybrid automated insulin delivery (AID) in active youth with type 1 diabetes. Research Design and Methods: In this double-blind multinational randomized crossover trial, 30 children and adolescents with type 1 diabetes (16 females; aged 15.0 ± 1.7 years; baseline HbA1c 7.5% ± 0.9% [58 ± 9.8 mmol/mol]) underwent two unrestricted 4-week periods using hybrid AID with either FIA or SIA in random order. During both interventions, participants were using the hybrid AID (investigational version of MiniMed™ 780G; Medtronic). Participants were encouraged to exercise as frequently as possible, capturing physical activity with an activity monitor. The primary outcome was the percentage of sensor glucose time above range (180 mg/dL [10.0 mmol/L]) measured by continuous glucose monitoring. Results: In an intention-to-treat analysis, mean time above range was 31% ± 15% at baseline, 19% ± 6% during FIA use, and 20% ± 6% during SIA use with no difference between treatments: mean difference = -0.9%; 95% CI: -2.4% to 0.6%; P = 0.23. Similarly, there was no difference in mean time in range (TIR) (78% and 77%) or median time below range (2.5% and 2.8%). Glycemic outcomes during exercise or postprandial periods were comparable for the two treatment arms. No severe hypoglycemia or diabetic ketoacidosis events occurred. Conclusions: FIA was not superior to SIA with hybrid AID system use in physically active children and adolescents with type 1 diabetes. Nonetheless, both insulin formulations enabled high overall TIR and low time above and below ranges, even during and after documented exercise. Trial Registration Clinicaltrials.gov: NCT04853030.

Unraveling the enigma: A complex case of severe diabetic ketoacidosis in a 12-year-old female with type 1 diabetes and concurrent tuberculosis

ABSTRACT This case report explores the intricate presentation of a 12-year-old female with type 1 diabetes, who exhibited severe diabetic ketoacidosis complicated by concurrent tuberculosis. Despite initial mismanagement and poor medication compliance, a multidisciplinary approach successfully unraveled the complexity of her condition. The case highlights the challenges in diagnosing and managing dual pathologies in pediatric patients, emphasizing the importance of a comprehensive and collaborative medical strategy.

Foot drop in children with newly diagnosed type 1 diabetes: three case reports.

The etiology of foot drop is diverse from various diseases to mechanic injuries and includes neuropathy of the peroneal nerve. Peroneal neuropathy might also be one of the forms of diabetic neuropathy, very rarely reported as the first sign of diabetes. We describe three cases of children with newly diagnosed type 1 diabetes (TID) who developed unilateral peroneal nerve palsies and tibial nerve palsies, presenting clinically as a foot drop. In two of our cases, the symptoms of foot drop occurred shortly after starting treatment for severe diabetes ketoacidosis. In the third patient, food drop was a reason for the initial medical consultation, but eventually, TID was diagnosed. The presented cases highlight that neuropathy can be observed not only as a chronic complication of T1D, but it can also appear at the time of disease manifestation. The incorrect position of the lower limb during a keto coma may contribute to the development of neuropathy. Neuropathy can be observed not only as a chronic complication of type 1 diabetes (T1D), but it can also appear at the time of disease manifestation. The incorrect position of the lower limb causing external pressure during a keto coma may contribute to the development of neuropathy. It is important to examine the glycemia in patients with acute peroneal neuropathy, as this kind of peripheral neuropathy can be associated with newly diagnosed T1D. Normalization of glycemia might lead to rapid neuronal recovery.

Severe diabetic ketoacidosis and coronavirus 2019 (COVID19) infection led to diagnosis of Autoimmune Polyglandular Syndrome

To this day, millions of people in the world have been diagnosed with corona virus 2019 (COVID-19). This disease cannot only lead to higher mortality rates among those with underlying Diabetes Mellitus (DM), but also may trigger DM in susceptible patients. Therefore, incidence of new-onset DM increased during the pandemic as a result; treatment of patients with diabetes and COVID-19 is important and needs further investigations. Here, we report a 27-year- old woman with past medical history of premature ovarian failure (POF) since14 years ago, who initially presented with severe diabetic ketoacidosis (DKA) which was triggered by COVID-19 and later through her lab results hypoparathyroidism was also detected. She was treated for DKA and COVID-19 Infection concomitantly, and she was also diagnosed with autoimmune polyglandular syndrome due to her multiple autoimmune endocrine organ involvements.

Severe diabetic ketoacidosis complicated with severe dyslipidemia, cerebral edema and acute kidney injury in a pediatric girl with type 1 diabetes mellitus: a case study

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic complication occurring in patients with type 1 diabetes, due to an insulin deficiency. Moderate hypertriglyceridemia is commonly observed in DKA but severe hypertriglyceridemia with a triglyceride level exceeding 10 g/l is very rarely reported. Acute kidney injury (AKI) is a serious condition which still carries a mortality of around 50%. Cerebral edema is a devastating complication of DKA which is leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of 8-year-old girl who presented with severe DKA, whose clinical course was complicated by renal failure, severe dyslipidemia and cerebral edema.

Diabetes Self-Care Management (DSCM) experience individuals with type 2 diabetes mellitus

Background : Self-Care Management is an important part of the lives of individuals with chronic diseases. This is important because they have to adapt their conditions so that they are able to make decisions about how to manage their own health condition. (Objective) This study aims to gain an in-depth understanding of the meaning of diabetes self-care management (DSCM) in type 2 diabetic individuals .&#x0D; Method: This study uses a qualitative method with a descriptive phenomenological approach. The sampling technique used was purposive sampling. Data saturation occurred in the 4th participant so the participants involved in this study were 4 people with inclusion criteria consisting of 1) Diabetes Mellitus Type 2 (DMT2) individuals with a period of ≥ 6 months; 2) those who did not experience severe complications (such as severe stroke, heart disease, and diabetic ketoacidosis; 3) was able to tell his experience. Data were taken through in-depth interviews for approximately 60 minutes. Data analysis using Colaizzi’s method.&#x0D; Results: The results of the study identified nine themes, including 1) physical responses experienced by people with Diabetes Mellitus Type 2 (T2DM); 2) perception; 3) Self-awareness; 4) routine blood sugar control; 5) adherence to diet; 6) physical activity; 7) adhere to treatment; 8) self-efficacy; 9) non-pharmacological therapy lowers blood sugar levels.&#x0D; Conclusion: DSCM is important in the management of Diabetes Mellitus Type 2 (DMT2). A better DSCM can reduce complications, reduce visits to health services, and treatment costs and reduce morbidity and mortality. Further research is needed to explore the content stored in DSCM.&#x0D; &#x0D; Key words: Diabetes self-care management, Diabetes mellitus Type 2 (DMT2), qualitative&#x0D;

1838-PUB: Impact of COVID-19 on New-Onset Pediatric Diabetes Diagnoses

Introduction: Global trends show an increased number of pediatric patients with newly diagnosed diabetes who present in severe diabetic ketoacidosis (DKA) during the COVID-19 pandemic. Methods: Medical records were reviewed for pediatric patients &amp;lt;18 years of age with new onset diabetes mellitus (DM) diagnosed two years pre-pandemic and two years during the COVID pandemic. Data collected included demographic, biochemical, and hospitalization data. Logistic regression was used to investigate the relationship between BMI, hemoglobin A1c, duration of hospital stay, DKA, and pandemic time frame. Results: A total of 175 cases of new onset DM were diagnosed during the study period; 54% post-pandemic. This represents a 16% increase in incident cases in the post-pandemic period. The sample was 55.4% male, 74.9% White/Caucasian, and 33.1% non-Hispanic. Type 1 DM comprised 136 cases. Inpatient diagnoses were the same in both the pre- and post-pandemic periods, n=75. Outpatient diagnoses during the pandemic period (n=19) were significantly higher than in the pre-pandemic period (n=6), X2(1) = 5.83, p &amp;lt; 0.05. The overall logistic regression model was statistically significant, X2(7) =18.35, p &amp;lt; 0.05. Hemoglobin A1c (p &amp;lt; 0.05, OR = 0.756, 95% CI [0.606, 0.945]) and length of hospital stay (p &amp;lt; 0.05, OR = 0.586, 95% CI [0.381, 0.902]) were significantly different between the two time periods, but BMI percentile (p = 0.869) and bicarbonate levels (p = 0.962) were not. Discussion: There was an increased incidence of new onset DM diagnosed in pediatric patients post-COVID. Surprisingly, outpatient cases accounted for the increased number. This study showed that during the pandemic, patients presented with a higher hemoglobin A1c and stayed longer in the hospital than prior to the pandemic. Disclosure K.Simms: None. S.Green: None. M.Shah: None. M.Sareini: None. C.Chin: None.

Meglumine Sodium Succinate in Diabetic Ketoacidosis

The most common agent used for infusion therapy in patients with diabetic ketoacidosis (DKA) is isotonic 0.9% sodium chloride solution. However, infusion of required volumes can result in development of iatrogenic complications — i. e., worsening of metabolic hyperchloremic acidosis in DKA patients with already altered acid-base balance. Balanced crystalloid solutions can be used as alternative to saline.Objective. To evaluate the feasibility of using meglumine sodium succinate (MSS) balanced crystalloid solution in DKA.Material and methods. We examined 2 groups of patients, 30 subjects each, with moderate and severe diabetic ketoacidosis admitted to anesthesiology and intensive care unit. Patients from both groups were administered with insulin and an infusion therapy was employed according to current clinical guidelines for the management of patients with complications of diabetes mellitus. In the comparison group, infusion therapy included 0.9% sodium chloride, 4% potassium chloride, and 5% dextrose. In the study group MSS intravenous drip infusions 10 ml/kg/daily were added to the infusion protocol. Volumes and infusion rates were comparable in both groups. The following indicators were evaluated: time to resolution and DKA resolution rates during thorough monitoring (first 48 hours of therapy), the time (in hours) before discontinuation of insulin infusion; the time to complete consciousness recovery (15 items on the Glasgow Coma scale); the duration (in hours) of stay in the intensive care unit (ICU), dynamics of blood electrolytes; parameters of acid-base balance; levels of glycemia and lactatemia.Results. All patients improved and were transferred from ICU, the mortality rate was 0%. Infusion of MSS shortened the time to DKA resolution (30.0 h [24.0 h; 36.0 h] in the study group, vs 44.5 h [36.5 h; 51.5 h] in the comparison group (P=0.001)); DKA resolution rates during 48 hours from initiation of therapy achieved 90.0% (27) in the study group, vs 66.7% (20) in the comparison group (P=0.060)); duration of intravenous insulin infusion was 32.0 h [24.5 h; 40.0 h] in the study group vs 48.0 h [40.0 h; 55.5 h] in the comparison group (P=0.001)); duration of ICU stay was 41.0 h [30.0 h; 48.0 h] in the study group, vs 56.0 h [50.0 h; 66.3 h] in the comparison group (P=0.001).Conclusion. Infusion of a balanced succinate-containing crystalloid solution improves the results of DKA treatment, as compared to traditional infusion of 0.9% sodium chloride.

Case Report: Diabetic ketoacidosis after co-administration of empagliflozin and probenecid

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are filtered and secreted to their primary site of action in the proximal tubule of the kidney. Many commonly used medications have potential to diminish renal elimination of SGLT2 inhibitors by inhibiting their tubular secretion. We present a case of severe diabetic ketoacidosis (DKA) in a patient with type 2 diabetes occurring several days after co-prescription of empagliflozin and probenecid. Other than the recent introduction of empagliflozin, no cause for the DKA episode was apparent. A pharmacokinetic interaction between probenecid and empagliflozin, involving organic anion transporter 3 (OAT3), reduces proximal tubular secretion of empagliflozin. Co-administration of an OAT3 inhibitor, such as probenecid, with empagliflozin may increase patient exposure and diminish glucosuric response to the SGLT2 inhibitor, thereby increasing the risk of DKA. We suggest that clinicians exercise caution when prescribing empagliflozin alongside inhibitors of OAT3 in patients with type 2 diabetes.

1365-P: Recurrent Diabetic Ketoacidosis—Patient Characteristics and Clinical Outcomes in Qatar

Background: Recurrent diabetic ketoacidosis (DKA) is associated with poor clinical outcomes. Objective: We aimed to examine patients’ characteristics and clinical outcomes for patients hospitalized with recurrent DKA in Qatar. Methods: The hospital database was interrogated for patients admitted with DKA to government hospitals in Qatar between 2015 to 2020. Precipitating cause, clinical characteristics, laboratory data, severity of DKA, complications, need for admission to the intensive care unit, length of hospital stay, time to resolution of DKA, and mortality rates were evaluated in patients with recurrent (&amp;gt;1 admission) compared to a single admission. Results: A total of 1612 episodes of DKA, of which 434 patients (26.9%) had recurrent DKA, were evaluated. Compared to patients who had a single admission for DKA, those with recurrent DKA were younger [35.0 (24.0-53.0) vs 39.0 (28.0-54.0) years, p&amp;lt;0.001], more likely to be females (50.6% vs 37.1%, p&amp;lt;0.001), more likely to have type 1 diabetes (47.9% vs. 33.4%, p&amp;lt;0.001), a longer duration of diabetes [12.0 (5.0-19.0 vs 5.0 (0.0-13.0) years, p&amp;lt;0.001], more likely to have severe DKA (48.6% vs 38%, p&amp;lt;0.001), with a shorter time to resolution of DKA [12.5 (9.0-24.0) vs 23.0 (10.0-33.0) hours, p&amp;lt;0.001]. There was no difference in the precipitating cause of DKA, need for admission to the intensive care unit, hospital stay or inpatient mortality. On multivariable logistic regression analysis, significant predictors of occurrence of recurrent DKA were younger age (OR, 0.96; 95% CI, 0.95-0.98; p= 0.0001), female gender (OR, 0.63; 95% CI, 0.46-0.85; p= 0.003) and longer duration of diabetes (OR, 1.07; 95% CI, 1.04-1.09, p= 0.0001). Conclusion: In this cohort study, recurrent DKA was associated with younger age, female predominance and longer duration of diabetes. However, hospital course and inpatient mortality rates did not differ from those with a single admission for DKA. Disclosure M.Eledrisi: None. I.Alabdulrazzak: None. H.M.Alkabbani: None. M.K.Aboawon: None. A.A.Ali: None. M.F.Elhaj: None. A.O.E.Ahmed: None. H.Alqahwachi: None. R.A.Malik: None.

104-LB: Interim Analysis of a Prospective Study Investigating User Satisfaction and Metabolic Outcome of People with T1D Using an Innovative Modular Micropump System

Aims: People with type 1 diabetes (T1D) can administer insulin by multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Despite proven clinical benefits, the uptake of CSII is still low. Thus, this study investigates the change in treatment satisfaction and metabolic outcome of people with T1D switching from MDI to CSII therapy using an innovative modular micropump system. Methods: A total of 50 CSII-naive adults with T1D from Argentina were enrolled in a multi-center, prospective, single-armed study for the Accu-Chek® Solo micropump system (ACS). Change in diabetes treatment satisfaction after 13 weeks (mean 108, min 83, max 176 days) was assessed by the “Impact and Satisfaction” section of the Diabetes Technology Questionnaire (DTQ) as primary outcome. In addition, changes in the DTQ after 1 year and the HbA1c after 13 weeks and 1 year were measured. Results: The change score of the “Impact and satisfaction” part of the DTQ was 113.37 ± 16.74 (mean ± SD, p &amp;lt; 0.0001) after 13 weeks and 111.42 ± 14.42 (p &amp;lt; 0.0001) after 1 year (with 90 as non-change score). Based on predefined sub-categories, the following mean DTQ change scores were measured after 13 weeks / 1 year: 3.81 ± 0.61 / 3.79 ± 0.52 for “diabetes distress and burden”, 3.96 ± 0.68 / 3.98 ± 0.60 for “hypoglycemia fear, worry and behavior”, 3.56 ± 0.71 / 3.53 ± 0.52 for “device acceptance and satisfaction” (1 = much worse, 5 = much better). The mean HbA1c decreased from 8.20 % ± 1.34 to 7.92 % ± 1.18 (-0.28 %pt, p = 0.0341) after 13 weeks and 7.87 % ± 1.26 (-0.37 %pt, p = 0.0467) after 1 year. Thereby, one event of severe hypoglycemia and diabetic ketoacidosis (DKA) was reported during 17520 device days. Conclusion: The switch from MDI to CSII using the ACS led to a significant improvement of subjects’ treatment satisfaction and HbA1c. Effects were already measurable after 13 weeks and continued through 1 year indicating that using the ACS reduces disease burden among people with T1D. Disclosure A. Dain: None. S. Moceri: Employee; Roche Diabetes Care. N. Dagenbach: Employee; Roche Diabetes Care. C. Rees: Employee; Roche Diabetes Care. C. Vulcano: Employee; Roche Diabetes Care. G. Vogt: Employee; Roche Diabetes Care. T. J. Etter: None.

141-LB: Cost-Effectiveness of Real-Time Continuous Glucose Monitoring (rt-CGM) vs. Intermittent-Scanning Continuous Glucose Monitoring (is-CGM) from a U.S. Payer Perspective in Patients with Type 2 Diabetes on Multiple Daily Injections of Insulin (PwT2D on MDI)

Diabetes management for PwT2D on MDI requires access to timely glucose readings to inform treatment decisions and avoid acute events like severe hypoglycemia (SHE) and Diabetic Ketoacidosis (DKA). CGM systems have different features that can impact glycemic outcomes and disease complications and costs. There is a gap in the literature on the cost-effectiveness of rt-CGM vs is-CGM systems. We conducted lifetime projections of disease outcomes and costs from a US payer perspective using the IQVIA Core Diabetes Model v9.5+. Cohort characteristics and clinical inputs were sourced from the DIAMOND T2D and REPLACE RCTs. Applying Bucher's adjusted indirect comparison method resulted in an HbA1c effect of -0.33 favoring rt-CGM, SHE incidence rates of 0.014 and 0 Per Person-Year (PPY) for is-CGM and rt-CGM, respectively, and DKA rates were estimated using Time-Above-Range (0.0313 and 0 PPY, respectively). The cost of both CGM systems is based on Medicare pricing and 80% reimbursement (HCPCS code A4239). A utility for fear of hypoglycemia (FoH) reduction was applied from the ALERTT1 RCT. The model associates rt-CGM use with reduced eye (-5.64%), renal (-7.42%), neural (-4.08%), and cardiovascular (-2.56%) complications compared to is-CGM. It projects rt-CGM users to have higher quality-adjusted life years (QALYs) by 0.454 with cost savings of -$1,355, and an incremental cost-effectiveness ratio of -$2,983/QALY. Rt-CGM remained cost-effective under the $50,000 willingness-to-pay threshold even when its cost was increased by 70% (+$1,713). Scenario analysis with 50% lower FoH utility, SHE, and DKA rates reduced QALYs gained to 0.264. Our analysis suggests that rt-CGM is cost-saving and cost-effective vs is-CGM in PwT2D on MDI in the US and can inform US payers of the economic value of different CGM systems. Disclosure H. Alshannaq: Employee; Dexcom, Inc., Other Relationship; Vertex Pharmaceuticals Incorporated. G. J. Norman: Employee; Dexcom, Inc. P. M. Lynch: Employee; Dexcom, Inc., Stock/Shareholder; Dexcom, Inc.

175-OR: Pregnancy Intervention with a Closed-Loop System (PICLS) Study

We performed a parallel, two-site, randomized controlled trial of a commercially available hybrid closed-loop (HCL) system compared to sensor augmented pump therapy (SAPT) in pregnant women with type 1 diabetes (T1D). Participants started SAPT (Medtronic 670G) by 11 weeks gestation, were randomized at 14-18 weeks, and continued therapy until 6 weeks postpartum. The HCL group used assistive techniques, “fake carbohydrate” boluses, to optimize therapy. We performed linear mixed model regression to compare outcomes between groups, adjusted for clinic. There were 24 women randomized and 23 completers. At baseline there were no significant differences between groups (mean baseline A1C 6.8% at 8w5d [SAPT]/9w0d [HCL] enrollment). There were no episodes of severe hypoglycemia or diabetic ketoacidosis after randomization. Adverse skin reactions occurred in 6 participants (5 SAPT vs 1 HCL, p=0.1550) with a median (IQR) number of 1 (1-2) SAPT vs 4 (4-4) HCL (p=0.8774). A1C significantly decreased from baseline to 2nd trimester, and was different between groups in the 3rd trimester (Table 1). There were no differences in time below, within, or above range between groups during the study (Table 1) or in gestational health outcomes (Table 2). In a pilot cohort of pregnant women with T1D, assisted HCL therapy did not increase risk to mothers or fetuses compared to SAPT despite lack of a pregnancy-specific algorithm in the HCL system. Disclosure E.Buschur: Consultant; Beta Bionics, Inc., Research Support; Dexcom, Inc., JDRF, Leona M. and Harry B. Helmsley Charitable Trust. E.R.Nease: None. S.Polsky: Other Relationship; diaTribe, Research Support; Dexcom, Inc., Medtronic, Hemsley Charitable Trust, JDRF, NIH - National Institutes of Health. J.K.Snell-bergeon: None. L.Pyle: None. R.Garcetti: None. K.M.Dungan: Board Member; Elsevier, Consultant; Eli Lilly and Company, Dexcom, Inc., Other Relationship; UpToDate, Research Support; Dexcom, Inc., Abbott, ViaCyte, Inc., Sanofi, Speaker's Bureau; Academy for Continued Healthcare Learning, Cardiometabolic Health Congress, Medscape, Integritas. S.F.Thung: None. A.Bartholomew: None. T.Summerfield: None. T.Bloks: None. Funding JDRF (2-SRA-2018-666-M-R); Colorado Clinical and Translational Sciences Institute; Children’s Diabetes Foundation; National Center for Research Resources (UL1RR02578)