Association Between Health Insurance Type and Adverse Outcomes for Children and Young Adults With Type 1 Diabetes and Coronavirus Disease 2019.

Background: Health insurance coverage type differs significantly by socioeconomic status and racial group in the United States. The aim of this study was to determine whether publicly insured children and young adults with type 1 diabetes were more likely to experience adverse outcomes compared with privately insured patients with acute coronavirus disease 2019 (COVID-19) infections. Methods: Data from 619 patients with previously established type 1 diabetes who were <24 years of age with acute COVID-19 infections were analyzed from the T1D Exchange COVID-19 surveillance registry. Data for the registry was collected from 52 endocrinology clinics across the United States using an online survey tool. Each site completed the survey using electronic health record data between April 2020 and December 2021. Results: Of the 619 patients included in this study, 257 had public insurance and 362 had private insurance. Of the 257 publicly insured patients with COVID-19, 57 reported severe adverse outcomes (22%), defined as diabetic ketoacidosis (DKA) or severe hypoglycemia. In comparison, there were 25 reported adverse outcomes (7%) among the 362 privately insured patients. Conclusion: Our data reveal high rates of hospitalization and DKA among publicly insured racial/ethnic minority children and young adults with type 1 diabetes and COVID-19.

Adrenal Crisis Masked as Septic Shock in a Patient With Opioid Use Disorder on Buprenorphine.

Opioid-induced adrenal insufficiency is a known side effect of chronic opioid use, but opioid-induced adrenal insufficiency related to chronic buprenorphine-naloxone therapy is less well-known. We present a case of a patient with opioid use disorder on chronic buprenorphine-naloxone therapy admitted with presumed septic shock and found to be in an adrenal crisis. The patient presented to our hospital with a shock-like presentation, requiring vasopressors, intubation, empiric glucocorticoids, and antibiotics. As her steroids were weaned, she developed bradycardia and blood glucose in the 60s. A low- and high-dose cosyntropin stimulation test confirmed the presence of secondary adrenal insufficiency, presumed to be due to her chronic buprenorphine-naloxone use. She was discharged on maintenance hydrocortisone and continued buprenorphine-naloxone therapy. With the high prevalence of opioid use disorder and the common need for medication for opioid use disorder, it is important that healthcare providers properly identify opioid-induced adrenal insufficiency in order to quickly and correctly diagnose and treat adrenal crises.

Non-glycemic Adverse Effects of Insulin.

Insulin is primarily considered for its glycemic effects in patients with diabetes. There are, however, non-glycemic adverse effects of insulin that may significantly impact patient health and interfere with glycemic control. Insulinogenic edema primarily occurs with rapid improvement in glycemic control either in patients with newly discovered diabetes or in patients with poorly-controlled diabetes. Insulin-induced sympathetic activation, vasodilation, changes in vascular permeability, and most importantly, sodium retention play significant etiologic roles in the development of edema. Clinically, it is usually self-limited, but significant complications can develop. Allergic reactions to all insulin preparations and various compounds used in insulin formulations with a wide range of severity have been reported. Frequently, changing the type of insulin or delivery method is sufficient, but more advanced treatments such as insulin desensitization and anti-IgE antibody treatment may be needed. Lipohypertrophy and lipoatrophy frequently develop with the overuse of injection sites. Lipohypertrophy can affect tissue insulin absorption and glycemic control.