Posted Jun 19 , 2018 04:36 AM

Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality —United States, 2000–2014

Benoit SR, et al. Morbidity and Mortality Weekly Report 2018;67:362-365

What were the findings (excerpted from the Article)

Diabetic ketoacidosis (DKA) is a life-threatening but preventable complication of diabetes characterized by hyperglycemia (>250 mg/dL), metabolic acidosis, and increased ketone concentration that occurs most frequently in persons with type 1 diabetes. CDC’s United States Diabetes Surveillance System (USDSS) indicated an increase in hospitalization rates for DKA during 2009–2014, most notably in persons aged <45 years. To explore this finding, 2000–2014 data from the Agency for Healthcare Research and Quality’s National Inpatient Sample (NIS) were assembled to calculate trends in DKA hospitalization rates and in-hospital case-fatality rates. Overall, age-adjusted DKA hospitalization rates decreased slightly from 2000 to 2009, then reversed direction, steadily increasing from 2009 to 2014 at an average annual rate of 6.3%. In-hospital case-fatality rates declined consistently during the study period from 1.1% to 0.4%. DKA rates were age-adjusted using four age groups (<45, 45–64, 65–74, and ≥75 years) from the 2000 U.S. Census. Joinpoint regression models, which identify points where linear trends change significantly in direction or magnitude, were used to analyze trends in DKA hospitalization and case-fatality rates. In the final model, each trend segment was described by an annual percent change, and the trend for each period was tested to determine whether the slope was significantly different from zero. From 2000 to 2009, the age-adjusted rate of DKA hospitalizations among persons with diabetes fluctuated but declined at an average annual rate of 1.1%. During 2009–2014, however, the rate increased 54.9%, from 19.5 to 30.2 per 1,000 persons, at an average annual rate of 6.3%. The reversal in trend was apparent across all age groups and both sexes. Rates were highest in persons aged <45 years (44.3 per 1,000 in 2014) and lowest in persons aged ≥65 years (<2.0 per 1,000).

Why is this important?

While no one cause can be found for this increase in DKA hospitalization rates, perhaps it is a composite of several possible explanations include the following: changes in case definition, new medications that might increase the risk for DKA, and higher admission rates because of lower thresholds for hospitalization. In the early 2000s, an increase in DKA cases among persons with obesity and type 2 diabetes was reported. These patients had impaired insulin levels but lacked typical autoimmune markers of type 1 disease, and their beta-cell function recovered quickly after treatment. This disease type, named ketosis-prone type 2 diabetes, has features of both type 1 and type 2 disease. While sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of prescription medications used to treat type 2 diabetes, were approved in March 2013. In December 2015, the Food and Drug Administration added a label to SGLT2 inhibitors warning that these medications might increase the risk for DKA. Because SGLT2 inhibitors were only recently approved, and DKA rates increased before their introduction, they are likely not a major contributor to the increasing DKA trend, but do remain an ongoing concern for future events. The good news is that mortality from episodes of DKA has decreased. Evidence based, targeted prevention measures such as diabetes self-management education and support might help reverse the trend in this potentially life-threatening but avoidable complication of diabetes.

Read the Article