Meeting NewsPerspective

Higher HbA1c, daily insulin injections increase diabetic ketoacidosis risk

LOS ANGELES — Adults with type 1 diabetes and HbA1c levels of at least 9% are more likely to develop diabetic ketoacidosis, or DKA, than those who reach lower targets, according to findings presented at AACE Annual Scientific and Clinical Congress.

Carol H. Wysham

“Achieving glycemic control remains a major barrier to the health and well-being of patients with type 1 diabetes. In addition to the known long-term vascular complications of hyperglycemia, patients with the poorest glycemic control are also at the highest risk for DKA,” Carol H. Wysham, MD, FACE, FACP, Endocrine Today Editorial Board member and clinical professor of medicine at the University of Washington Rockwood Clinic/MultiCare Health System in Seattle, told Endocrine Today. “Health care providers should continue to monitor and educate all patients on the risk factors associated with developing DKA, and be vigilant in patients with HbA1c greater than 9%.”

Wysham and colleagues conducted a cross-sectional analysis of 6,242 participants in the 2016-2017 Type 1 Diabetes Exchange Clinical Registry. Episodes of diabetic ketoacidosis were identified with questionnaires, and participants were divided into categories based on HbA1c levels of 7% to less than 8%, 8% to less than 9%, and at least 9%. Most participants in the study cohort fell within the 7% to less than 8% range (43%), followed by the 8% to less than 9% range (31%) and the 9% or more range (30%).

A higher percentage of participants with HbA1c levels in the 9% or more range had an episode of DKA (9.5%) compared with the 7% to less than 8% group (1.7%) and the 8% to less than 9% group (2.3%). According to Wysham, those in the 9% and higher group were five times more likely to have a DKA event than those in the 7% to less than 8% group and four times more likely that those in the 8% to less than 9% group.

Multivariate-adjusted models revealed associations between DKA incidence and a number of socioeconomic factors, including household income, smoking status and insulin delivery method, according to Wysham, who said that those with HbA1c of 9% or more who used daily injections “had significantly higher risk of DKA than pump users.”

“Ongoing education to our adult patients on recognizing and avoiding DKA is an important part of clinical practice for patients with type 1 diabetes,” Wysham said. “Patients with poor glycemic control, especially those with HbA1c greater than 9%, are at higher risk for developing DKA, and understanding contributing associated factors such as those identified in our work can [help] clinicians gauge those at greatest risk.” – by Phil Neuffer

Reference:

Wysham C, et al. Incidence and associated risk factors of diabetic ketoacidosis in hyperglycemic adult patients with type 1 diabetes. Presented at: AACE Annual Scientific and Clinical Congress; April 24-28, 2019; Los Angeles.

Disclosure: Wysham reports her institution has received research funding from Mylan and Novo Nordisk, and she has served in an advisory, consolatory and speaking role for Abbott, AstraZeneca, Boehringer Ingelheim, Dexcom, Janssen, Novo Nordisk and Sanofi.

LOS ANGELES — Adults with type 1 diabetes and HbA1c levels of at least 9% are more likely to develop diabetic ketoacidosis, or DKA, than those who reach lower targets, according to findings presented at AACE Annual Scientific and Clinical Congress.

Carol H. Wysham

“Achieving glycemic control remains a major barrier to the health and well-being of patients with type 1 diabetes. In addition to the known long-term vascular complications of hyperglycemia, patients with the poorest glycemic control are also at the highest risk for DKA,” Carol H. Wysham, MD, FACE, FACP, Endocrine Today Editorial Board member and clinical professor of medicine at the University of Washington Rockwood Clinic/MultiCare Health System in Seattle, told Endocrine Today. “Health care providers should continue to monitor and educate all patients on the risk factors associated with developing DKA, and be vigilant in patients with HbA1c greater than 9%.”

Wysham and colleagues conducted a cross-sectional analysis of 6,242 participants in the 2016-2017 Type 1 Diabetes Exchange Clinical Registry. Episodes of diabetic ketoacidosis were identified with questionnaires, and participants were divided into categories based on HbA1c levels of 7% to less than 8%, 8% to less than 9%, and at least 9%. Most participants in the study cohort fell within the 7% to less than 8% range (43%), followed by the 8% to less than 9% range (31%) and the 9% or more range (30%).

A higher percentage of participants with HbA1c levels in the 9% or more range had an episode of DKA (9.5%) compared with the 7% to less than 8% group (1.7%) and the 8% to less than 9% group (2.3%). According to Wysham, those in the 9% and higher group were five times more likely to have a DKA event than those in the 7% to less than 8% group and four times more likely that those in the 8% to less than 9% group.

Multivariate-adjusted models revealed associations between DKA incidence and a number of socioeconomic factors, including household income, smoking status and insulin delivery method, according to Wysham, who said that those with HbA1c of 9% or more who used daily injections “had significantly higher risk of DKA than pump users.”

“Ongoing education to our adult patients on recognizing and avoiding DKA is an important part of clinical practice for patients with type 1 diabetes,” Wysham said. “Patients with poor glycemic control, especially those with HbA1c greater than 9%, are at higher risk for developing DKA, and understanding contributing associated factors such as those identified in our work can [help] clinicians gauge those at greatest risk.” – by Phil Neuffer

PAGE BREAK

Reference:

Wysham C, et al. Incidence and associated risk factors of diabetic ketoacidosis in hyperglycemic adult patients with type 1 diabetes. Presented at: AACE Annual Scientific and Clinical Congress; April 24-28, 2019; Los Angeles.

Disclosure: Wysham reports her institution has received research funding from Mylan and Novo Nordisk, and she has served in an advisory, consolatory and speaking role for Abbott, AstraZeneca, Boehringer Ingelheim, Dexcom, Janssen, Novo Nordisk and Sanofi.

    Perspective
    Shane (Peter) Hamblin

    Shane (Peter) Hamblin

    The finding that HbA1c above 9% was associated with five times the DKA risk compared to those with HbA1c below 8% will come as little surprise to the clinical endocrinologist, but it is very useful to have the risk quantified. This work puts the spotlight on a group of patients where more attention is needed. The association with insulin injections vs. insulin pumps may be explained by the fact that pump users tend to be financially better off or covered by insurance.

    The strengths of the study include the large number of patients and their representation across many areas of the US. Limitations include its cross-sectional nature and potential inaccuracies as it is based on questionnaires. Additionally, people attending type 1 diabetes exchange centers may represent a better controlled cohort compared to those who receive their clinical care elsewhere, as they may be managed by less-expert clinicians. It is possible that the findings may be even more pronounced in the wider type 1 diabetes community.

    The finding of an elevated HbA1c is akin to a patient in the ED with a fever. It is undoubtedly important information, but the underlying cause may be due to many things. We would not diagnose a fever and leave it at that. Similarly, the finding of an elevated HbA1c warrants an evaluation of the reasons behind the elevation: Is there concomitant depression or illicit drug use? Are there technical issues or educational factors or social disadvantage? Some of the contributing causes may be amenable to intervention and others not. One common and very difficult problem is that patients with the highest risk are also those who are most likely to be disengaged from specialized care.

    • Shane (Peter) Hamblin, MBBS (Hons), FRACP
    • Head of Endocrinology and Diabetes
      Western Health
      Melbourne, Australia

    Disclosures: Hamblin reports no relevant financial disclosures.

    See more from American Association of Clinical Endocrinologists Annual Meeting