Subcutaneous rapid-acting insulin analogues in mild to moderate diabetic ketoacidosis: A meta-analysis of randomized controlled trials.

INTRODUCTION: Diabetic Ketoacidosis (DKA) is commonly treated with intravenous (IV) regular insulin. However, patients with less severe DKA may benefit from a subcutaneous (SC) scheme. METHODS: We systematically searched PubMed, Cochrane, and Embase for randomized controlled trials (RCTs) comparing SC rapid-acting insulin analogue (RAIAs) with IV regular insulin. Risk ratios (RR) were used to compare treatment effects for binary outcomes and mean differences (MD) for continuous data with the corresponding 95 % confidence intervals (CI). P values <0.05 were considered statistically significant. We used the R version 4.3.2 for statistical analyses. RESULTS: Our meta-analysis included eight RCTs encompassing 415 patients. No statistically significant differences were found between RAIAs and IV regular insulin in the treatment of mild to moderate DKA in the pediatric and adult population in the primary outcome of time until DKA resolution (MD 0.00 h; 95 % CI -1.27 to 1.28; P = 1.00). Both treatments showed comparable results in the secondary outcomes total insulin usage (P = 0.65), time until hyperglycemia resolution (P = 0.22), length of hospital stay (P = 0.11), the incidence of hypoglycemia (P = 0.15) and DKA recurrence (P = Not estimable). There were no reports of death, cerebral edema, or venous thrombosis in the studies. CONCLUSION: In this meta-analysis of eight RCTs we found that SC RAIAs and regular IV insulin are comparable in resolving mild to moderate DKA in children and adults. PROSPERO registration: CRD42023485032.

Ketone Management in Pediatric Diabetes Centers in the USA: Current Practices and a Call for Improved Standardization.

INTRODUCTION: Diabetic ketoacidosis (DKA) is the leading cause of mortality among youth with type 1 diabetes (T1D). Guidelines for DKA prevention exist; however, specific guidance about when to check ketones and how to manage youth using insulin pumps and automated insulin delivery (AID) systems is lacking. METHODS: A 35-item online survey exploring clinical ketone management practices for youth with T1D in the USA was distributed to diabetes healthcare professionals (HCPs). Survey responses, including multiple-choice and Likert scale questions, were summarized and rates of agreement and disagreement (Likert scale 4, 5 vs. 1, 2, 3) are reported. RESULTS: In total, 123 HCPs (51% physicians, 26% diabetes educators, 19% nurse practitioners) from 47 institutions completed the survey. Seventy percent worked at academic specialty centers. Ninety-seven percent reported >50% continuous glucose monitoring use in their clinic and 72% reported >50% insulin pump use. Although 79% reported having ketone management protocols, the level and duration of hyperglycemia at which ketone monitoring was advised ranged from >200 to 350 mg/dL and from 0 min to >6 h of duration. While 72% had distinct ketone management protocols for pump users, only 29% had specific protocols for AID. Sixty-two percent agreed that DKA due to infusion site failure was a significant problem in their practice, and 70% agreed there was a need to standardize ketone management guidelines. CONCLUSIONS: The preventable nature and high incidence of DKA highlight the need to build consensus for clinical ketone management and to develop tools to facilitate management, especially as the use of diabetes technologies continues to increase.

Factors associated with severe diabetic ketoacidosis in patients diagnosed with type 1 diabetes: a decade-long cross-sectional analysis.

OBJECTIVE: The aim of this study was to identify factors associated with severe diabetic ketoacidosis (DKA) at the onset of type 1 diabetes mellitus (T1DM) in adult patients. METHODS: We conducted a retrospective analysis over a 10-year period including adults newly diagnosed with T1DM. Eligible participants were diagnosed with DKA at the time of T1DM diagnosis. DKA severity was categorized as mild, moderate, or severe. Data were collected on age, body mass index, family history of diabetes and autoimmune disorders, lifestyle habits, delayed diagnosis, and preceding factors. RESULTS: A total of 305 participants (69.8% men) with T1DM were included. Overall, 63 patients were admitted with severe DKA (Group 1) and 242 with non-severe DKA (Group 2). Factors associated with severe DKA at diagnosis of T1DM were a long period between symptom onset and first hospitalization, preceding infection, tachypnea, thrombocytopenia, anemia, hepatic cytolysis, polyuria, and tachycardia. CONCLUSIONS: The present findings highlight the need for improving awareness about diabetes symptoms among physicians and the public to reduce the occurrence and severity of DKA at the onset of T1DM.

Treatment Challenges and Controversies in the Management of Critically Ill Diabetic Ketoacidosis (DKA) Patients in Intensive Care Units.

This review discusses the challenges and controversies in the treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Key areas include the selection of intravenous (IV) fluids, insulin therapy, strategies for preventing and monitoring cerebral edema (CE) by managing hyperglycemia overcorrection, electrolyte replacement, timing of nutrition, use of IV sodium bicarbonate, and airway management in critically ill DKA patients. Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution. Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored potassium levels have been achieved and subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis. In comparison, the British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone. Although rare, rapid overcorrection of hyperglycemia with fluids and insulin can lead to CE, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for CE. DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia and regular monitoring is essential for DKA management. Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. Instead, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended. The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation. Managing DKA and HHS in critically ill patients includes using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin, early use of SQ glargine insulin, electrolyte replacement, and monitoring, CE preventive strategies by avoiding hyperglycemia overcorrection, early nutritional support, and appropriate airway management.

Insulin Pump Use and Diabetic Ketoacidosis Risk in Type 1 Diabetes: Secular Trends over Four Decades.

Introduction: Continuous subcutaneous insulin infusion (CSII) in type 1 diabetes has been regarded as a major diabetic ketoacidosis (DKA) risk factor. We aimed to determine secular trends in risk since CSII implementation in the 1980s. Research Design and Methods: We assessed the relationship between time-varying CSII use and DKA events from 1983 to 2017 and by each decade in the 1441 Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study participants using crude and adjusted Cox proportional hazards models. Results: Time-varying CSII exposure was associated with significantly higher DKA risk in the 1980s (adjusted hazard ratio [HR] 5.81; 95% confidence interval [CI] 3.28-10.29; P < 0.001), but in the 2010s, this risk was not significantly elevated (adjusted HR 1.24; 95% CI 0.73-2.12; P = 0.43). Conclusions: DKA risk associated with CSII in type 1 diabetes has declined substantially since the 1980s such that the remaining risk in the past decade appears to be of low magnitude.

Lemierre's syndrome associated-diabetic ketoacidosis in an elderly female: a case report.

BACKGROUND: The co-occurrence of Lemierre's syndrome, primarily triggered by Fusobacterium necrophorum following oropharyngeal infection, with diabetic ketoacidosis (DKA) in diabetes mellitus (DM) patients, underscores a rare but life-threatening clinical scenario. Lemierre's syndrome induced DKA is extremely rare, with only one case report in adult and no case yet reported in elderly. CASE PRESENTATION: We reported a case of a 69-year-old female who presented with DKA triggered by deep neck space infection (DNSI), leading to rapid clinical deterioration within 6 h that necessitated high flow nasal cannula (HFNC) and antibiotic administration. Laboratory findings included leukocytosis, elevated serum C-reactive protein, hyperglycemia, ketonemia, and severe metabolic acidosis. Culture of the fluid from a neck mass puncture drainage and blood were positive for Klebsiella pneumoniae. The patient was further complicated by thrombosis of the left internal jugular vein with extension to the sigmoid and a neck abscess surrounding the carotid artery sheath, consistent with Lemierre's syndrome. This condition was managed aggressively with fluid resuscitation, insulin therapy, surgical drainage, antibiotics, and anticoagulation led to a significant improvement in her condition. Following a 13-day hospitalization, there was significant clinical improvement, culminating in the patient's discharge. CONCLUSIONS: The case highlights the need for greater awareness and understanding of the interrelated and mutually promoting conditions of DKA and Lemierre's syndrome among clinicians. Early recognition and treatment are crucial to prevent mortality in such complex cases.

Sodium-Glucose Co-transporter-2 Inhibitors in Type 1 Diabetes Mellitus: The Framework for Recommendations for Their Potential Use.

The growing prevalence of overweight/obesity, the persistence of inadequate glycemic control among the majority of affected individuals, and the still unacceptably high risk of cardiovascular morbidity and mortality among population with type 1 diabetes mellitus (T1D), impose an urgent need for the introduction of non-insulin glucose-lowering agents in the therapeutic armamentarium. Given that their antihyperglycemic mechanism of action is independent of endogenous insulin secretion and that the observed cardio-renal benefits are unrelated to their glucose-lowering properties, one can speculate that the use of sodium-glucose co-transporter-2 inhibitors (SGLT2is) could provide benefits in T1D, similar to the ones observed among individuals with type 2 diabetes mellitus, chronic kidney disease (CKD), and heart failure. Available evidence from randomized controlled trials suggests that treatment with SGLT2is as adjunct to insulin in T1D results in modest reductions in glycated hemoglobin and body weight. Additionally, SGLT2is ameliorate albuminuria, and thus delay or prevent the development of CKD in T1D. However, use of SGLT2is is associated with an increased risk of diabetic ketoacidosis (DKA) in T1D. This commentary aims at providing a framework for practical recommendations regarding the potential use of SGLT2is in adults with T1D, based on the individual's risk level for DKA development, the presence of inadequate glycemic control and related cardio-renal complications.

Characteristics and clinical relevance of leukocytic response in children with diabetic ketoacidosis - A comparative cohort study.

Objective: Leukocytosis is often observed among children presenting with diabetic ketoacidosis (DKA). This study compares detailed parameters of leukocytosis in children presenting with DKA versus infection. Subjects and methods: In this comparative cohort study, we collected data from two groups of children, one hospitalized with DKA and another with community-acquired pneumonia (CAP). The primary objective was to compare the neutrophil-to-lymphocyte ratio (NLR) between the groups. Total leukocyte count (TLC), absolute neutrophil count (ANC), platelet-to-lymphocyte ratio (PLR), and platelet-to-monocyte ratio (PMR) were also compared. The correlation of these hematological parameters with the clinical outcomes in the DKA group was also explored. Results: Data from 35 children with DKA (mean age 7.4 years, 12 boys) and 40 children with CAP (mean age 7.9 years, 15 boys) were available for comparison. No significant NLR difference was observed between the DKA and CAP groups. Similarly, no significant difference was observed in TLC and ANC between the groups. However, significant differences between the DKA and CAP groups were observed regarding mean (standard deviation) PLR (108.26 [67.51] versus 166.60 [163.83], respectively, p = 0.01) and mean PMR (1,795.40 [4,307.00] versus 886.33 [1,726.41], p = 0.01). Among children with DKA, ANC and PMR correlated positively and hemoglobin level correlated negatively with unfavorable outcomes. Conclusions: Specific parameters of leukocytosis (PLR and PMR) differed significantly in children with DKA versus CAP. Some widely available and inexpensive hematological parameters of inflammation (hemoglobin, ANC, and PMR) may predict outcomes in patients with DKA.

A Case of Acute Hypertriglyceridemia-Induced Pancreatitis in Pregnancy and Its Clinical Implications.

Acute hypertriglyceridemia-induced pancreatitis (HTGP) is an uncommon occurrence during pregnancy. Prompt diagnosis and initiation of treatment are indicated to prevent adverse maternal and neonatal outcomes. We present the case of a pregnant female who was diagnosed with HTGP at 34 weeks gestation and subsequently developed diabetic ketoacidosis (DKA) and preeclampsia with severe features. We describe the pathophysiology of acute HTGP and its relation to the gravid state and review available treatment options though data remains limited. Our case emphasizes the potential sequelae of HTGP in pregnancy, the need for a multidisciplinary approach for optimal care, and the importance of early treatment in improving maternal and neonatal outcomes.

Characterizing the relationship between social determinants of health and risk of albuminuria among children with type 1 diabetes.

In a cohort of 2303 children with type 1 diabetes (T1D), we found that non-English speaking status (HR 2.82, 95% CI 1.54-5.18) and public insurance (HR 1.48, 95% CI 1.07-2.05) were associated with an increased risk of incident albuminuria, after adjusting for T1D-related variables (age, hemoglobin A1c, diabetic ketoacidosis episodes with acute kidney injury).

In-hospital initiation of sodium-glucose co-transporter-2 inhibitors in patients with acute heart failure.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors provide cardiovascular and kidney benefits to patients with heart failure (HF) and/or chronic kidney disease (CKD), regardless of diabetes status and left ventricular ejection fraction (LVEF). Despite robust data demonstrating the efficacy of SGLT-2 inhibitors in both ambulatory and hospital settings, real-world evidence suggests slow and varied adoption of SGLT2 inhibitors among patients hospitalized for HF. Barriers to implementation of SGLT2i may include clinicians' concerns regarding potential adverse events such as diabetic ketoacidosis (DKA), volume depletion, and symptomatic hypoglycemia; or concerns regarding physiologically expected reductions in eGFR. Guidelines lack specific, practical safety data and definitive recommendations regarding in-hospital initiation and continuation of SGLT2i in patients hospitalized with HF. In this review, we discuss the safety of in-hospital SGLT2 inhibitor initiation based on recent trials and highlight the clinical implications of their early use in patients hospitalized for HF.

Effectiveness of Dexamethasone for COVID-19 in Hospitalized Patients with Diabetes: A Retrospective Cohort Study.

BACKGROUND: Patients with diabetes have higher mortality from COVID-19 compared to the general population. Dexamethasone, a potent glucocorticoid used for moderate to severe COVID-19, can worsen hyperglycemia in patients with diabetes, potentially leading to worse outcomes. The efficacy and safety of use of dexamethasone for COVID-19 in patients with diabetes needs further evaluation. OBJECTIVE: The study aimed to assess the efficacy and safety of dexamethasone in patients with diabetes hospitalized for COVID-19 infection. DESIGN: This retrospective study analyzed data from five hospitals in the Johns Hopkins Health System (JHHS) collected between March 3, 2020 and June 25, 2022. Propensity score matching was applied to a cohort of patients with diabetes who received dexamethasone and those who did not (controls), and outcomes were compared using Cox proportional hazards regression models. OUTCOMES: The primary outcome was time to death within 28 days. The secondary outcome was time to clinical improvement. Additional outcomes included the incidence of hyperglycemic emergencies and subgroup analysis of primary outcomes by clinical severity. RESULTS: Out of 10,329 patients admitted for COVID-19, 3,679 had diabetes, and 2,361 met the inclusion criteria. After propensity score matching, 529 patients were analyzed in each group. Survival rates between the dexamethasone and control groups during the 0-6 day and 7-28-day periods and time to clinical improvement at 28 days did not differ significantly. There was no difference in the incidence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) between the groups. CONCLUSION: Dexamethasone treatment did not significantly improve survival or time to clinical improvement in patients with diabetes and COVID-19 infection. Further prospective studies are needed to confirm these findings and determine potential mechanisms.

Successfully managed alcoholic ketoacidosis with sepsis leading to multiple organ dysfunction syndrome: a case report.

We present the case of a 28-year-old male with a history of alcohol dependency and smoking, who presented with chest pain, shortness of breath, and altered sensorium. He exhibited severe metabolic acidosis, hypoglycemia, low platelet count, and acute kidney injury. Alcoholic ketoacidosis was suspected due to ketonuria, metabolic acidosis, and ketonemia, compounded by electrolyte abnormalities and radiographic findings of pneumonia.

Euglycemic Ketoacidosis Associated with SGLT-2 Inhibitors in Non-diabetic Patients-A Narrative Review.

Euglycemic ketoacidosis is an acute, life-threatening emergency that is characterized by euglycemia, metabolic acidosis, and ketonemia. It is a well-recognized adverse event in diabetic patients taking sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor). However, there is limited data on SGLT-2 inhibitor-related euglycemic ketoacidosis in non-diabetic patients. The mechanism behind SGLT-2 inhibitor-associated euglycemic ketoacidosis involves a general state of starvation or relative insulin deficiency, which exacerbates the mild baseline ketonemia caused by this class of medications while normoglycemia is maintained. The incidence of euglycemic ketoacidosis will likely increase with the increasing use of SGLT-2 inhibitors for various indications in addition to diabetes mellitus type 2, predominantly for congestive heart failure (CHF). Recognizing the signs and symptoms of this life-threatening condition is essential to treat it effectively. Our objective is to comprehensively revisit the pathophysiology of euglycemic ketoacidosis associated with SGLT-2 inhibitors and the risk factors for the condition, review the available data, and summarize the reported cases of euglycemic ketoacidosis in non-diabetic patients on SGLT-2 inhibitors. Our literature search identified five articles with six cases of euglycemic ketoacidosis in non-diabetic patients who were on SGLT-2 inhibitors for heart failure with reduced ejection fraction. The common risk factor in five out of the six cases was decreased oral intake due to acute illness, fasting, or a perioperative state.

Hamman Syndrome Caused by a Sodium Glucose Cotransporter 2 Inhibitor in an Elderly Patient with Diabetes which Mimicked of Boerhaave Syndrome.

A 70-year-old man with diabetes was treated with a sodium glucose cotransporter 2 (SGLT2) inhibitor. He developed vomiting and epigastric pain and was diagnosed with diabetic ketoacidosis (DKA). Computed tomography (CT) revealed mediastinal emphysema. As Boerhaave syndrome could not be ruled out, treatment was initiated in parallel with DKA treatment. After the DKA healed, the mediastinal emphysema disappeared. DKA combined with mediastinal emphysema is known as Hamman syndrome. There have been no reports of Hamman syndrome in elderly patients with diabetes caused by SGLT2 inhibitors. His symptoms mimicked the course of Boerhaave syndrome, and such cases have a high risk of misdiagnosis.

A Case of Diabetic Ketoacidosis With Severe Hypertriglyceridemia and Slowly Resolving Metabolic Acidosis.

Diabetic ketoacidosis (DKA) is a critical metabolic complication observed in newly diagnosed cases of type 1 diabetes. Severe hypertriglyceridemia, diagnosed in this case, is a rare consequence of DKA. A six-year-old female child presented to the casualty with drowsiness, reduced oral acceptance, difficulty in breathing, hyperglycemia for the past four hours, and polyuria for the past two and a half months. On examination, tachypnea and Kussmaul breathing were present, and the patient was drowsy and confused with a Glasgow coma scale score of 12/15. Grossly lipemic serum was obtained during routine sampling with deranged international normalized ratio (INR), severe hypertriglyceridemia, and refractory metabolic acidosis. According to the International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines 2023, maintenance fluids were administered intravenously as per blood sugar levels with potassium supplementation, including a deficit of 10%. Insulin was given intravenously at 0.1 IU/kg with a broad-spectrum antibiotic.

The role of ACPs in recognising and treating diabetic ketoacidosis and hyperosmolar hyperglycaemic state.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are both diabetic emergencies that require immediate identification and intervention. Advanced clinical practitioners (ACPs) play a crucial role in the early detection, management and co-ordination of care for patients with these conditions, although some may feel less confident in handling such complex cases. This clinical review explores the role of ACPs in managing DKA and HHS, focusing on their responsibilities in diagnosis, treatment initiation, and communication within multidisciplinary teams. It also examines the epidemiology, pathogenesis, risk factors, and causes of these conditions, alongside diagnostic criteria and management strategies. In addition, the review highlights the importance of minimising risks and preventing recurrence to ultimately enhance patient outcomes.

In vitro ß-hydroxybutyrate stability evaluation in femoral blood and vitreous humor for integration into forensic toxicology practices.

Thanatological biochemistry has gained prominence in determining causes of death, especially when suspected fatal pathologies do not exhibit clear postmortem macroscopic and/or microscopic features, such as in cases of ketoacidosis. Indeed, in these cases, the measurement of ß-hydroxybutyrate (BHB) in femoral blood and/or vitreous humor is of particular importance. However, data on its in vitro stability remain scarce, especially in vitreous humor. In this context, the study reported here aims to assess the in vitro stability of BHB. BHB quantification was performed using a liquid chromatography coupled with tandem mass spectrometry method. To investigate BHB stability, two different postmortem matrices were considered: femoral blood and vitreous humor. These matrices were pooled, aliquoted and spiked with BHB at three different concentrations (50 mg/L, 100 mg/L, and 200 mg/L; n = 3). Initial BHB concentrations were established on day 1. Each sample was then divided into two aliquots for storage under two conditions: 20 °C and 4 °C. Analyses were performed on Day 3, 7, 14, and 28. The study revealed no significant degradation of BHB in femoral blood or vitreous humor over time (days 1-28), confirming the robustness and reliability of BHB measurement in these matrices as a postmortem biomarker of ketoacidosis under the tested temperature conditions (+4 °C or -20 °C). These results support a systematic integration of BHB measurement into the routine workflow of forensic toxicology laboratories.

Determining factors influencing hospital stay for individuals admitted with diabetes-related ketoacidosis - findings from DEKODE length of stay quality improvement project.

There are significant variations in discharge post-diabetes-related ketoacidosis (DKA) hospitalisation, yet there is a paucity of research to understand or minimise the reasons. This quality improvement project (QIP) aimed to identify reasons for post-DKA discharge delays and assess intervention efficacy. Utilising the Digital Evaluation of Ketosis and Other Diabetes-related Emergencies (DEKODE) model, data from 177 DKA episodes from January 2021 to September 2023 across three hospitals were analysed. Factors affecting discharge were investigated through a plan, do, study, act (PDSA) methodology. While interventions focused on optimising data collection and refining discharge guidelines, no significant reduction in DKA duration or length of stay was observed. Findings highlight post-DKA hospitalisation's multifaceted nature and the limited impact of simple interventions. Collaborative efforts and further research are necessary to develop effective strategies for expedited discharge and improved patient care. This study's comprehensive tracking and analysis tool offers valuable insights for future interventions in managing DKA-related hospitalisations.

Clinical features and outcomes of patients diagnosed with diabetic ketoacidosis (DKA) who were hospitalized for conditions outside of internal medicine.

AIMS: To assess the clinical features and outcomes of patients diagnosed with DKA who were hospitalized for conditions outside of internal medicine. METHODS: Retrospective analysis of admissions for DKA in adult patients between 2005 and 2022 at a tertiary hospital in Israel. Patients with DKA were stratified into medical vs non-medical groups, the primary outcome was in-hospital mortality. RESULTS: 429 patients were included in the study, 385 patients (89.7 %) were treated by an internal medicine team, while 44 patients (10.3 %) were hospitalized with surgical or obstetrical conditions. Patients in the non-internal medicine group were older (52 ± 18.9 vs 43.6 ± 20.4, p < 0.005) and had higher rates of diabetes complications such as chronic ischemic heart disease (20.5 % vs. 4.2 %, p < 0.0001) and chronic kidney disease (50 % vs. 3.4 %, p < 0.001). Glucose level on presentation was lower for non-internal medicine patients (398 ± 221 mg/dL vs 551 ± 180 mg/dL) and outcomes of mechanical ventilation and length of hospitalization were more severe (29.5 % vs. 6 %, p < 0.001 and 8.0 vs. 3.0, p < 0.001). Multivariate analysis demonstrated that composite outcome of in-hospital mortality, ICU admission and longer hospitalization was more likely in the non-internal medicine group (OR 3.99, CI 1.89-8.4, p < 0.001). CONCLUSION: DKA is a universal pathology that concerns various medical fields. It is essential for every clinician to be familiar with this condition. Patients diagnosed with DKA who were hospitalized for conditions outside of internal medicine may be at high risk and may present with lower glycemic levels. Future research is needed to characterize the unique features of subgroups of patients with DKA.