A case series of diabetic ketoacidosis associated with SGLT2 inhibitors

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are increasingly initiated as treatment for type 2 diabetes due to favourable cardiorenal characteristics. However, studies have identified an increased risk of diabetic ketoacidosis (DKA). We carried out a retrospective, case-based study at East and North Herts NHS Trust between February 2018 and December 2020. Fifteen cases of SGLT2i associated DKA were identified in people with presumed type 2 diabetes;33.3% were classed as euglycaemic DKA with a blood glucose of <11mmol/L. All cases were associated with a significant precipitating factor including diarrhoea, vomiting, reduced oral intake and sepsis. One case was related to COVID-19. Two people were subsequently found to have raised islet autoantibodies suggesting type 1 diabetes or latent autoimmune diabetes in adults. It is important that awareness of SGLT2i associated DKA is raised among users and health care practitioners, including the recognition of euglycaemic DKA. Sick day rules should be emphasised and reiterated at clinical encounters. Non-specialists in primary care, oncology and in perioperative settings should be empowered to advocate for temporary withdrawal and there should be readier access to blood ketone monitoring when required. When SGLT2i associated DKA occurs, due consideration should be given to evaluate the diabetes classification and investigate the circumstances of the event. Copyright © 2023 John Wiley & Sons.Copyright © 2023 John Wiley & Sons, Ltd.

Impact of free insulin scheme to patients with type 1 diabetes during Covid-19 pandemic

Aim: Our institute provided the required monthly insulin free to patients with type 1 diabetes, where either patients or parents became unemployed and/or economically weaker during the pandemic. Method(s): All 296 patients with type 1 diabetes were given questionnaires to assess their or their family's economic status during Covid-19. 33 patients fell below poverty line and had a Priority Household Card (with 35kgs of free rice every month) and ration cards enrolled for monthly free insulin scheme. The patients were given monthly requirements of insulin based on existing regimens. Their weight, HbA1c and episodes of ketoacidosis were measured at 3-and 6-months following initiation of the scheme. Additional financial and material support were organized from NGO's and philanthropic individuals. Measurable impact of this project was ascertained through glycaemic control through HbA1C levels prior and after, overall wellbeing and prevention of acute complications like ketoacidosis. Result(s): 33 patients enrolled for the study, 9 were less than 15 years of age, 19 between 15 and 30 years and 5 above 30 years of age. HbA1c levels fell cumulative by 0.8% by 3 months and 1.2% by six months. Weight increased by 1 kg by 3 months and 1.5 kg by six months. Few episodes of ketoacidosis were reported during six months primarily due to engagement issues issue rather than availability of insulin. Conclusion(s): There was a dramatic impact on overall wellbeing of these patients with type 1 diabetes with significant improvement on glycaemic control and on emotional by reducing the financial burden of procuring monthly doses of insulin.

Frequency of Diabetes Mellitus and Newly Diagnosed Hyperglycemia and Their Impacts on Hospitalized COVID-19 Patients

Background: The coronavirus disease 2019 (COVID-19) pandemic and its associated morbidities are a great global concern. Diabetes mellitus (DM) is associated with adverse clinical outcomes and high mortality in patients with COVID-19. Objective(s): This study examined the frequency of BM, newly diagnosed hyperglycemia, and their impacts on hospitalized patients with COVID-19. Method(s): This retrospective study examined 810 medical records of PCR-confirmed COVID-19 patients admitted to Razi Hospital, Ahvaz, Iran. The clinical presentations, severity, and impacts of COVID-19 were compared between patients with and without DM. Disease severity was determined based on the NEWS2 scoring system. Result(s): This study included 810 medical records of COVID-19 patients, of whom 326 had pre-existing DM, and 484 were non-DM. The rates of diabetes and newly diagnosed hyperglycemia were 40.2% and 11.2%, respectively. The most common underlying diseases were hypertension (35.3%), ischemic heart disease (17.9%), and chronic kidney disease (11.9%), which were higher in people with diabetes than non-diabetics. The rate of acute kidney injury was higher in patients with diabetes than in non-diabetics (30.7% vs. 19.2%;P < 0.001) and in patients with severe COVID-19 than in those whose disease was not severe (27.8% vs. 21.5%;P = 0.04). The rates of severe COVID-19 (46.3% vs. 34.7%;P = 0.093), ICU admission (40.7% vs. 27.4%;P = 0.012), and mortality (18.5% vs. 10.5%;P = 0.079) were higher in patients with newly diagnosed hyperglycemia than in euglycemic patients. Conclusion(s): This study showed that COVID-19 infection is linked with newly diagnosed hyperglycemia and pre-existing DM, both associated with severe COVID-19, more need for ICU admission, and mortality.Copyright © 2023, Author(s).

Complex presentations in people with diabetes: Does HbA1c help or hinder?

HbA1c measurement is widely used for diagnosis/ management/remission of diabetes with international schemes certifying comparability. A) 75 year-old Chinese female with type 2 diabetes was admitted in April 2020 with Covid-19 and diabetic ketoacidosis. Glucose was 35mmol/l and HbA1c 150mmol/mol with previous HbA1c of 45mmol/mol on metformin and alogliptin. She was treated for ketoacidosis and once-daily Lantus introduced along with supportive management of viral illness. B) 68 year-old Afro-Caribbean with type 2 diabetes on metformin before admission, presented with new onset, jerky ballistic movements of high amplitude in right arm, 10-15 movements every 5 min. Admission glucose was >33mmol/l, ketones 1.8mmol/l and HbA1c >217mmol/ mol. Hemichorea-hemiballism, a hyperglycaemia related movement was diagnosed and insulin commenced. Glucose decreased to 8-20mmol/ l, reaching 5-15mmol/ l by time of discharge. Ballistic movements resolved when glycaemic control improved with HbA1c 169mmol/mol, 25 days after discharge. C) Several days before admission, a female with diabetes over 20 years required attention from paramedics on four occasions for hypoglycaemia. Months beforehand metformin was replaced by gliclazide due to chronic kidney disease with HbA1c 50mmol/mol, and she was transfused six weeks before admission for microcytic anaemia. Gliclazide was discontinued and her diet modified which prevented further hypoglycaemic episodes. Variant haemoglobin, beta-thalassaemia which can overestimate glycaemia;undetected by HbA1c HPLC method, invalidated HbA1c as did the blood transfusion. These cases highlight that inadequate understanding of HbA1c can lead to acute presentations of dysglycaemia. As HbA1c accuracy can be affected by multiple factors, clinical assessment and triangulation are key to the management of such patients.

Biochemical mechanisms in the severe prognosis of pa- tients with diabetes mellitus infected by SARS-CoV-2 virus: literature review

Diabetes mellitus (DM) is a metabolic disease characterised mainly by signs and symptoms derived from increased serum glucose or hyperglycemia. The coronavirus disease 2019 (COVID-19) pandemic affected the entire world with reports of severe prognosis in diabetic patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and high hospital admissions in the intensive care unit (ICU) compared to non-diabetic patients. The objective of the bibliographic review was to evaluate and describe some of the biochemical mechanisms that lead to severe prognosis in patients with DM infected by the SARS-CoV-2 virus through a systematic search for information in different databases. The results showed that the high ICU admission with a severe prognosis of diabetic patients infected by the virus was due to excessive inflammation that causes acute respiratory distress syndrome, cytokine storm, severe pneu-monia, impaired immunity, and hyperglycemia. The virus enters the cell mainly through the endocytic and non-endosomal pathway;the central cellular receptors involved in the mechanisms are insulin receptors (IR), glucose transporter type 2 (GLUT-2), dipeptidyl peptidase-4 (DPP4), glucose transporter type 4 (GLUT-4), glucose converting enzyme angiotensin 2 (ACE2), and the serine transmembrane protease co-receptor 2 (TMPRSS2) essential for viral propagation. The increased susceptibility to devel-oping COVID-19 in diabetic patients is due to the overexpression of ACE2, and serious complications are increased at the microvascular and macrovascular levels, such as nephropathies, neuropathies, and cardiovascular diseases.

An audit looking at why there is an increase in the number of patients with type 2 diabetes presenting in diabetic ketoacidosis in a tertiary hospital

Objectives: To investigate why a tertiary hospital has a high number of patients with type 2 diabetes presenting with diabetic ketoacidosis. Method(s): An audit was carried out looking at all of the inpatient admissions for diabetic ketoacidosis in patients with type 2 diabetes between 2021 and 2022. Any patient with a coding of diabetic ketoacidosis and type 2 diabetes had their inpatient clinical notes evaluated using the following criteria: 1) Were the criteria for diabetes ketoacidosis met? 2) Patient age. 3) Patient anti-diabetic medications. 4) If relevant, who prescribed a sodium-glucose cotransporter- 2 inhibitor and was sick day rule advice given? 5) Did the patient have a concurrent Covid-19 infection? Results: Almost a quarter of patients (24%) included in this audit did not fulfil the diagnostic criteria for diabetic ketoacidosis. For those that did: -Over a quarter of patients (26%) were on sodium-glucose cotransporter-2 inhibitors with the majority being commenced by GPs (81%). There was no documentation as to whether sick day rule advice had been given. -Only 7% of patients had a concurrent Covid-19 infection. -The majority of patients (68%) were aged less than 75 years. Conclusion(s): Coding on discharge summaries is important and junior doctors may need further guidance with regards to the diagnostic criteria for diabetic ketoacidosis. Sodium-glucose cotransporter-2 inhibitors inhibitors are a significant cause of diabetic ketoacidosis in patients with type 2 diabetes and patient sick day rule advice is needed prior to initiation. Covid-19 infection wasn't found to be a significant causative factor.

The impact of the COVID-19 pandemic on critically ill patients with acute stroke and diabetic ketoacidosis

Introduction and aim. This study aimed to compare the hospitalization rate, mortality rate and morbidity status of patients hospitalized with stroke and diabetic ketoacidosis (DKA) before and during the COVID-19 pandemic. Material and methods. The data of 2522 patients who applied to the emergency department (ED) before and during the pandemic were evaluated. A Poisson regression analysis was used to examine the number of presentations between two different periods. Results. Stroke cases during the pandemic era were compared to those during the pre-pandemic period, and it was shown that the mortality rate for stroke patients during the pandemic period was much higher. Treatment-related ED presentations decreased significantly during the pandemic period, particularly among patients aged 75-84 years. Rates of ED presentation decreased by 84 percent (IRR: 0.14, 95 percent CI: 0.03-0.59) in those with DKA and by 37 percent (IRR: 0.67, 95 percent CI: 0.53-0.75) in those with stroke during the pandemic period. Conclusion. Conclusion: Stroke and DKA admissions decreased during the pandemic, but the rate of stroke mortality increased statistically 3.375 times. Getting emergency medical care increases their chances of survival. Even in a COVID-19 outbreak, treatment is critical. © 2022 Publishing Office of the University of Rzeszow. All Rights Reserved.

Ketoacidosis as a primary manifestation of COVID-19.

INTRODUCTION: Diabetic ketoacidosis is the most important metabolic emergency in children. Children mimic many syndromes with a combination of nonspecific symptoms during the COVID-19 pandemic. Many syndromes are triggered by changes in children's body conditions. Reporting specific cases can improve the diagnosis process. The present study reports an 18-month-old paediatric case of COVID-19 who presented ketoacidosis (DKA) symptoms. CASE PRESENTATION: The case is an 18-month-old child with fever and diarrhoea from 3 days before, who did not respond to outpatient treatment. On the day of the visit, he suffered from deep and abdominal breathing and decreased level of consciousness and sugar levels at admission of 420 mg/dl. He was then admitted with the initial diagnosis of DKA and had a positive PCR test result for COVID-19. CONCLUSIONS: Considering the non-specific symptoms of COVID-19, general practitioners and paediatricians are recommended that special attention be paid to these symptoms, especially those that are similar to life-threatening syndromes. They also should not easily ignore these symptoms and follow up patients and their recovery status and, if patients do not recover, consider the risk of COVID-19 given the current COVID-19 pandemic.

Acute pancreatitis associated with diabetic ketoacidosis in a child with COVID-19 infection.

BACKGROUND: There is a mutual influence between COVID-19, diabetes ketoacidosis, and acute pancreatitis, with clinical manifestations overlapping each other, which can lead to misdiagnosis and delayed treatment that could aggravate the condition and affect the prognosis. COVID-19-induced diabetes ketoacidosis and acute pancreatitis are extremely rare, with only four case reports in adults and no cases yet reported in children. CASE PRESENTATION: We reported a case of acute pancreatitis associated with diabetic ketoacidosis in a 12-year-old female child post novel coronavirus infection. The patient presented with vomiting, abdominal pain, shortness of breath, and confusion. Laboratory findings showed elevated levels of inflammatory markers, hypertriglyceridemia, and high blood glucose. The patient was treated with fluid resuscitation, insulin, anti-infection treatments, somatostatin, omeprazole, low-molecular-weight heparin, and nutritional support. Blood purification was administered to remove inflammatory mediators. The patient's symptoms improved, and blood glucose levels stabilized after 20 days of admission. CONCLUSION: The case highlights the need for greater awareness and understanding of the interrelated and mutually promoting conditions of COVID-19, diabetes ketoacidosis, and acute pancreatitis among clinicians, to reduce misdiagnosis and missed diagnoses.

COVID-19 vaccination and diabetic ketoacidosis.

An efficient coronavirus disease 2019 (COVID-19) vaccine is urgently required to fight the pandemic due to its high transmission rate and quick dissemination. There have been numerous reports on the side effects of the COVID-19 immu-nization, with a focus on its negative effects. Clinical endocrinology is extremely interested in the endocrine issue that arises after receiving the COVID-19 vaccine. As was already mentioned, after receiving the COVID-19 vaccine, many clinical problems could occur. Additionally, there are some compelling reports on diabetes. After receiving the COVID-19 vaccine, a patient experienced hyperosmolar hyperglycemia state, a case of newly-onset type 2 diabetes. There has also been information on a potential connection between the COVID-19 vaccine and diabetic ketoacidosis. Common symptoms include thirst, polydipsia, polyuria, palpitations, a lack of appetite, and weariness. In extremely rare clinical circumstances, a COVID-19 vaccine recipient may develop diabetes complications such as hyperglycemia and ketoacidosis. In these circumstances, routine clinical care has a successful track record. It is advised to give vaccine recipients who are vulnerable to problems, such as those with type 1 diabetes as an underlying illness, extra attention.

SARS-CoV-2 Positive Serology and Islet Autoantibodies in Newly Diagnosed Pediatric Cases of Type 1 Diabetes Mellitus: A Single-Center Cohort Study.

Acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, although presenting less severe forms of the disease in children, seems to play a role in the development of other conditions, including type 1 diabetes mellitus (T1DM). After the beginning of the pandemic, an increase in the number of T1DM pediatric patients was observed in several countries, thus leading to many questions about the complex relationship between SARS-CoV-2 infection and T1DM. Our study aimed to highlight possible correlations between SARS-CoV-2 serology and T1DM onset. Therefore, we performed an observational retrospective cohort study that included 158 children diagnosed with T1DM in the period April 2021-April 2022. The presence or absence of SARS-CoV-2 and T1DM-specific antibodies and other laboratory findings were assessed. In the group of patients with positive SARS-CoV-2 serology, a higher percentage had detectable IA-2A antibodies, more children were positive for all three islet autoantibodies determined (GADA, ICA, and IA-2A), and a higher mean HbA1c value was found. No difference existed between the two groups regarding DKA presence and severity. A lower C-peptide level was found in the patients presenting diabetic ketoacidosis (DKA) at T1DM onset. When compared to a group of patients diagnosed before the pandemic, an increased incidence of both DKA and severe DKA, as well as a higher age at diagnosis and higher levels of HbA1c were present in our study group. These findings have important implications for the ongoing monitoring and management of children with T1DM after the COVID-19 pandemic and highlight the need for further research to better understand the complex relationship between SARS-CoV-2 infection and T1DM.

A Quality Improvement Project Impacts Resident Satisfaction with the Depart Process

Purpose of Study The current depart process resulted in slow work-flow and patient safety and equity concerns. The QI project aimed to improve resident satisfaction with the hospital discharge process. Methods Used The QI project was designed using the Model for Improvement. Starting April 2020, Plan-Do-Study-Act cycles included: hiring clinical team coordinators;creating standard depart instructions for diabetic ketoacidosis, pyelonephritis, seizures, croup and dehydration;uploading instructions to Powerchart;and clinician reminders to use instructions with families. Measures examined monthly, included resident satisfaction and patient readmissions. Summary of Results Resident satisfaction improved from 4.8 (February 2020) to 7.8 (August 2020) for the overall discharge process;from 5.3 to 7.9 for family education on all key points;from 6.0 to 7.7 for smooth transition of care;from 3.0 to 7.4 for no language barriers;and from 3.0 to 6.7 for no unnecessary delays, on a scale of 0/strongly disagree/ terrible to 10/strongly agree/excellent. Readmissions also trended downward. Conclusions During this QI project to address the depart process, resident satisfaction improved and readmissions declined. These results are encouraging, but should be interpreted in the context of decreased patient census due to COVID-19 and non-respiratory season, which may have decreased workload and increased education time and interpreter access. Next steps include PDSAs related to health literacy and Spanish translation.

The First Reported Case of Lorlatinib-Associated Diabetic Ketoacidosis

Introduction: Lorlatinib is a third-generation tyrosine kinase inhibitor that inhibits anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1). Although 2-10% of patients with non-small cell lung cancer developed hyperglycemia in phase 2 and 3 studies of lorlatinib, only one case has subsequently reported hyperglycemia >500 mg/dL, and no cases of diabetic ketoacidosis (DKA) have been previously reported. Phase 1 trials in neuroblastoma are ongoing. Case Description: A 34-year-old woman with ALK-mutated paraspinal neuroblastoma presented with DKA 14 months after initiation of lorlatinib. Prior to starting lorlatinib, her hemoglobin A1c had been 5.0% (n: < 5.7%). After 12 months of therapy, her A1c increased to 7.8%, prompting the initiation of metformin 500 mg daily. However, two months later she was admitted for DKA with a blood glucose of 591 mg/dL (n: 65-99 mg/dL), CO2 17 mmol/L (n: 20-30 mmol/L), anion gap 18 (n: 8-12), moderate serum ketones, and 3+ ketonuria. Her A1c was 14.8%, C-peptide was 1.2 ng/mL (n: 1.1-4.3 ng/mL), and her glutamic acid decarboxylase-65 and islet antigen-2 autoantibodies were negative. She was also found to be incidentally positive for COVID-19 but was asymptomatic without any oxygen requirement. The patient's DKA was successfully treated with IV insulin infusion, and she was discharged after 3 days with insulin glargine 27 units twice daily and insulin aspart 16 units with meals. One month later, her hemoglobin A1c had improved to 9.4%, and the patient's oncologist discontinued lorlatinib due to sustained remission of her neuroblastoma and her complication of DKA. After stopping lorlatinib, her blood glucose rapidly improved, and she self-discontinued all her insulin in the following 3 weeks. One month later, she was seen in endocrine clinic only taking metformin 500 mg twice daily with fasting and post-prandial blood glucose ranging 86-107 mg/dL. Discussion(s): This is the first reported case of DKA associated with lorlatinib. This case highlights the importance of close glucose monitoring and the risk of severe hyperglycemia and DKA while on lorlatinib therapy. Discontinuation of lorlatinib results in rapid improvement of glycemic control, and glucose-lowering treatments should be promptly deescalated to avoid hypoglycemia.Copyright © 2023

The Impact of COVID-19 Infection on Diabetic Ketoacidosis Acidosis Hospitalization: A Nationwide Analysis

Objective: One of the potentially fatal consequences for diabetic patients is diabetic ketoacidosis acidosis (DKA), which is also linked to poor hospital outcomes. There is no much information in literature about COVID-19 and how it relates to other hospitalizations. The impact of COVID-19 on in-hospital mortality and other clinically relevant outcomes for DKA patients is being investigated for the first time in this study. Method(s): Patients admitted with a primary diagnosis of DKA with or without a subsequent diagnosis of COVID-19 Infection were found in the National Inpatient Sample (NIS) Database 2020. Patients were divided into two groups: those who have COVID-19 and those who don't. Univariate and multivariate logistic regression models were utilized to account for frequent confounders and assess the risk of mortality and in-hospital outcomes between the two groups. Result(s): The total of 110,130 DKA admissions were identified between Jan and Dec 2020. COVID-19 Infection was diagnosed in 2,504 patients (2.2%). The average age of the cohort sample was 35 years old, 51% were male, and 60% were white. The average length of stay (LOS) was 3 days, and the average total hospital charges were 33,132 US dollars. The total number of patients who died was 225 patients. When the two groups were compared, COVID-19 Infection was associated with an increased risk of in-hospital mortality among DKA patients (OR 5.3, 95% CI 1.7-15.9, p=0.003). COVID-19 patients had a higher risk of acute respiratory failure (OR 2.9, 95% CI 1.7-3.9, p< 0.001) and septic shock (OR 3.9, 95% CI 1.5-9.8, p=0.003). There was no significant difference between the COVID-19 and non-COVID-19 groups in the risk of acute coronary syndrome (OR 1.2, 95% CI 0.49-3, p=0.66), cardiac arrest (OR 2, 95% CI 0.5-7.9, p=0.31), hypokalemia (OR 1.14, 95% CI 0.92-1.4, p=0.214), deep vein thrombosis (OR 0.59, 95% CI 0.14-2.4, p=0.47), or pulmonary embolism (OR 3.6, 95% CI 0.84 - 15.4, p=0.083). COVID-19 patients had a longer mean LOS (4.2 vs 2.9 days, p< 0.001) and higher mean total hospital charges (41,216 vs 32,973 $, p=0.004). Discussion/Conclusion: Patients admitted with DKA and concomitant COVID-19 infection found to have a higher risk of in-hospital mortality and worse hospital outcomes, particularly acute respiratory failure and septic shock. In comparison to non-COVID patients, COVID-19 patients have a longer mean LOS and a higher mean of total hospital charges.Copyright © 2023

Staging of COVID-19 disease, using selected laboratory profiles for predictionprevention and management of severe SARS-CoV-2 infection in Africa-review

There are many uncertainties on the future management of the coronavirus disease 19 (COVID-19) in Africa. By July 2021, Africa had lagged behind the rest of the world in Covid-19 vaccines uptake, accounting for just 1.6% of doses administered globally. During that time COVID 19 was causing an average death rate of 2.6% in Africa, surpassing the then global average of 2.2%. There were no clear therapeutic guidelines, yet inappropriate and unnecessary treatments may have led to unwanted adverse events such as worsening of hyperglycemia and precipitating of ketoacidosis in administration of steroid therapy. in order to provide evidence-based policy guidelines, we examined peer-reviewed published articles in PubMed on COVID 19, or up-to date data, we focused our search on publications from 1st May 2020 to 15th July, 2021. For each of the studies, we extracted data on pathophysiology, selected clinical chemistry and immunological tests, clinical staging and treatment. Our review reports a gross unmet need for vaccination, inadequate laboratory capacity for immunological tests and the assessment of individual immune status, clinical staging and prediction of disease severity. We recommend selected laboratory tools in the assessment of individual immune status, prediction of disease severity and determination of the exact timing for suitable therapy, especially in individuals with co-morbidities.Copyright © 2023 Sendagire H et al.

The Complexities of Managing Hypertriglyceridemia-Induced Pancreatitis in a Critically-Ill COVID-19 Patient

Introduction: Hypertriglyceridemia-induced pancreatitis (HTP) is a variant of pancreatitis requiring unique management. The complications of COVID-19 and its treatments can make HTP therapy more nuanced. This case describes a patient who presented in diabetic ketoacidosis (DKA) with HTP, and COVID-19. The patient developed renal and respiratory failure, necessitating hemodialysis (HD) and extracorporeal membrane oxygenation (ECMO), complicating an otherwise straightforward medical management plan. Case Description: A morbidly obese (BMI 38.9 kg/m2) 43-year-old male presented to an outside hospital with abdominal pain, and vomiting, and was found to have HTP with triglycerides (TG) >2000 mg/dL (<149 mg/dL) and presumed new-onset type 2 Diabetes (HbA1c 10.9%) with DKA. Treatment with fluids, intravenous (IV) insulin infusion and plasmapheresis were initiated. He developed hypoxia after receiving over 17 liters of fluids and was intubated, subsequently developing renal failure and was transferred to our tertiary center for HD and ECMO. On admission, he tested positive for COVID-19, rhabdomyolysis [creatinine kinase 5600 U/L (30-200 U/L)], HTP [TG 783 mg/dL (<149 mg/dL), lipase 461 U/l (7-60 U/L)], glucose 269 mg/dL (not in DKA), transaminitis [AST 184 U/L (4-40 U/L), ALT 61 U/L (4-41 U/L)] and renal failure (GFR 10 ml/min/1.73m2). IV insulin infusion was initiated for hyperglycemia worsened by COVID-19 dexamethasone treatment. Plasmapheresis was performed twice with minimal effect at maintaining a low TG. Fenofibrate was not initiated due to renal failure;Lovaza could not be given via oral gastric tube;Atorvastatin was attempted once rhabdomyolysis resolved, with subsequent worsening of liver function tests. Heparin infusion was initiated for deep vein thrombosis treatment and HTP but was stopped after development of heparin induced thrombocytopenia. The patient developed worsening hypoglycemia requiring cessation of IV insulin, hypotension requiring maximum pressor support, and worsening sepsis leading to his death. Discussion(s): This case illustrates the challenges of managing a patient with HTP and COVID-19. It demonstrates how a normally straightforward treatment algorithm can become increasingly complex when factoring the patient's comorbid conditions. The case highlights the importance of knowing both treatment indications and contraindications for HTP. In this case, HTP may have been the initial diagnosis, straightforward for most endocrinologists, but its treatments and comorbid conditions ultimately made the landscape more challenging, limiting effective management and ultimately leading to this patient's demise.Copyright © 2023

Diabetic Ketoacidosis in Children Before and During COVID-19 Pandemic: A Cross-sectional Study

Background: Coronavirus disease 2019 (COVID-19) has spread quickly. Comorbidities, such as diabetes, have been determined as critical risk factors for COVID-19. Objective(s): This study aimed to determine the frequency and severity of diabetic ketoacidosis (DKA) in children before and during the COVID-19 pandemic. Method(s): This retrospective study examined children aged less than 18 years diagnosed with DKA hospitalized in Yazd Shahid Sadoughi Hospital from February 20, 2020, to November 21, 2021. The collected information was compared to those obtained during the same period in 2019 (pre-pandemic). According to the inclusion criteria, only children with suspected symptoms of COVID-19 or an infected family member underwent PCR. Result(s): The study included 70 children with confirmed DKA during the COVID-19 pandemic and 33 children hospitalized during the pre-pandemic period. The findings showed that the rate of DKA was higher during the pandemic than in the pre-pandemic period. In the DKA subgroups (during the COVID-19 pandemic vs. pre-pandemic), 35.7% vs. 21.2% were severe, 37.1% vs. 36.4% were moderate, and 27.1% vs. 42.4% were mild. Of 70 children, 30 underwent PCR tests for COVID-19, showing six positive cases. Among positive cases, five had mild symptoms, while one was hospitalized with signs of respiratory distress, polyuria, and polydipsia. All physical examinations of this patient were normal, except for the chest exam. Conclusion(s): A remarkable increase was observed in the frequency and severity of DKA in children during the pandemic.Copyright © 2023, International Journal of Endocrinology and Metabolism. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Rates of Hypoglycemia with Reduced- vs. Standard-Dose Insulin for Hyperkalemia Treatment in Renal Insufficiency

Objective: The primary objective was to assess the difference in rates of hypoglycemia (blood glucose (BG) <=70 mG/dL) when using reduced-dose (5 units) vs. standard-dose (10 units) of IV regular insulin for hyperkalemia treatment in renal insufficiency. Secondary objectives include the efficacy of insulin dose on potassium reduction and evaluating the difference in rates of severe hypoglycemia (BG <=54 mG/dL) between the groups. Method(s): This was a retrospective chart review of patients with renal insufficiency treated with IV regular insulin for hyperkalemia at a tertiary care teaching hospital from June 2020 to June 2021, with institutional review board approval. Inclusion criteria encompassed patients aged 18 years and older with elevated baseline potassium (>=5.5 mEq/L), estimated glomerular filtration rate < 30 mL/min/1.73m2, end stage renal disease, or presence of acute kidney injury, having received either 5 or 10 units of IV regular insulin for hyperkalemia, and had documented glucose and potassium levels after insulin administration. Patients who were pregnant, had diabetic ketoacidosis, or a baseline BG <=70 mG/dL were excluded. Data collection included patient demographics, diabetes history, relevant labs at time of elevated potassium, doses of insulin and dextrose administered for hyperkalemia treatment, presence of coronavirus-19 infection, glucose levels within 6 hours and first potassium level within 24 hours following insulin administration, concurrent use of potassium-lowering agents, insulin outside of hyperkalemia treatment, or steroids, and mortality. Result(s): Out of 409 patients included, 92 were in the 10-unit group and 317 in the 5-unit group. The rate of hypoglycemia in the 5-unit arm vs. the 10-unit arm was 6.9% vs. 8.7% (p=0.649), respectively. The rate of severe hypoglycemia between the 5-unit arm and the 10-unit arm was 3.2% vs 5.4% (p=0.682), respectively. The percent normalization of potassium was not statistically different between the 5-unit group and the 10-unit group (59% vs. 68%;p=0.115), with the same mean reduction in potassium from baseline (0.8 mEq/L (p=0.947)). Administration of concurrent treatments for hyperkalemia was similar between the groups, with dialysis being the only one with statistical significance in normalization of potassium. Patient characteristics that could have an impact on risk of hypoglycemia were studied and analyzed, including pre-treatment BG, history of diabetes mellitus, insulin naive, and patient weight. In patients with hypoglycemia (n=30) vs. those without hypoglycemia (n=379), there was a significantly different mean pre-treatment BG (113 mG/dL vs. 178 mG/dL, p<0.001). Discussion/Conclusion: There was no significant difference in rates of hypoglycemia and severe hypoglycemia between the 5-unit vs. 10-unit groups. There was no significant change in potassium normalization between the two insulin doses. Because of the small number of hypoglycemia events, larger studies are needed to better understand if 5 units of regular insulin is a safer option for the treatment of hyperkalemia in renal insufficiency.Copyright © 2023

COVID-19 Viral Infection Presenting With Diabetic Ketoacidosis, Hyperosmolar Hyperglycemic Syndrome, or Mixed Hyperglycemic Crisis: A Case Series.

Cardiovascular disease, COPD, and diabetes (DM) are associated with increased complications with COVID-19. A correlation between COVID-19 and diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic Syndrome (HHS) has been suggested; however, the precise mechanism remains unclear. We present a case series of six patients with COVID-19 infections who were found to have DKA, HHS, or mixed picture. Wedescribe an association between COVID-19 and hyperglycemic emergencies. Six patients (50% male, 50% female, mean age 47.667 ± 18.747) were identified from November 2021 to February 2022. Comorbidities included DM (83.3%), HTN (50%), as well as ESRD, A-Fib, ISLD, HIV, and dementia (each 16.7%). Common review of systems included nausea and vomiting (50%), abdominal pain (33.3%), dyspnea (33.3%), and decreased appetite (33.3%). Additional findings were dysarthria, facial droop, generalized weakness, productive cough, myalgias, and increased urinary frequency (16.7%). Patients were diagnosed with DKA (50%), mixed process (33.3%), andHHS(16.7%). In terms of COVID-19 symptoms, most patients were asymptomatic (83.3%), with one patient developing hypoxia. The survival rate was 100%. Infections can incite DKA/HHS; yet, COVID-19 may have factors that amplify this process, in the setting of pancreatic beta-cell dysfunction from the virus itself. This may contribute to why diabetic patients have a ten times higher risk of death if they develop COVID-19. This virus binds to ACE2 receptors in the pancreas and damages the islets, ultimately decreasing insulin release. Here, we introduce cases of DKA/HHS in the setting of COVID-19, to understand the relationship between how COVID-19 infections may exacerbate diabetic complications.