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Disclosures: The authors report no relevant financial disclosures.
June 19, 2020
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Simplified management protocol can prevent, treat DKA in COVID-19

Source/Disclosures
Disclosures: The authors report no relevant financial disclosures.
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Alternative, patient-tailored strategies are needed to treat diabetic ketoacidosis in the setting of COVID-19 to better balance intensive insulin therapy with minimizing clinician exposure and preserving personal protective equipment.

Early reports indicate that among people with diabetes, DKA is a common and potentially fatal complication in hospitalized patients with COVID-19, Nadine Palermo, DO, associate director of acute diabetes care at Brigham and Women's Hospital, and colleagues wrote in a clinical perspective published in The Journal of Clinical Endocrinology & Metabolism. Some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing disease transmission to high-risk individuals, reducing health care worker exposure to infected patients and preserving personal protective equipment, the researchers wrote.

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“DKA typically requires hospital level of care and is often treated in the intensive care unit with IV insulin, which requires frequent bedside assessment,” Palermo told Healio. “In an effort to balance the need to provide intensive insulin therapy with minimizing exposure to health care workers and preserving personal protective equipment, we have found it to be extremely helpful to consider alternative strategies for patient triage and treatment. In our experience it has been safe and effective to consider use of subcutaneous insulin therapy outside of the ICU in select patient populations. We wanted to share this approach as using this protocol allowed us to reserve ICU beds for critically ill patients with COVID-19 and treat DKA in non-critical care areas.”

Insulin dosing concerns

IV insulin has been the most studied approach to administering variable-dose insulin to hospitalized patients with DKA; however, this poses a challenge in the setting of COVID-19 as it requires patient interactions every 1 to 2 hours, the researchers wrote. As an alternative method to protect patients and clinicians while preserving ICU beds, new strategies could include identifying patients who may be able to be treated outside of the hospital or for a short period in the ED.

“In select cases of mild to moderate DKA, subcutaneous insulin therapy and treatment outside of the ICU may be a useful strategy to address unique needs during a pandemic,” Palermo said. “In our experience, using this approach was an effective way to treat DKA, minimize exposure to health care workers and conserve personal protective equipment.”

Nadine Palermo

Researchers also noted that it is not recommended that hospitals make major changes to their current approach to managing DKA as this “may cause unintended consequences and result in the reverse outcome of requiring more ICU resources and time at the bedside.”

Prevalence of DKA

There are insufficient data to determine whether DKA is more prevalent in COVID-19 and whether the novel coronavirus poses an increased risk compared with other severe infectious diseases, the researchers wrote.

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In a study of 658 hospitalized patients with confirmed COVID-19, 42 patients (6.4%) presented with positive urine or serum ketones, and of these, three (7%) patients met the American Diabetes Association criteria for DKA, according to the researchers. Compared with those who did not develop ketosis, those with ketosis were about twice as likely to have diabetes at baseline, and the individuals who developed DKA had underlying diabetes, researchers wrote. Additionally, those who developed ketosis, with or without acidosis, were younger, had higher rates of acute respiratory distress, acute liver injury, digestive disorder, were more likely to require mechanical ventilation and had a longer length of hospital stay vs. those who did not develop ketosis.

“Ketosis was also associated with higher mortality,” the researchers wrote. “Larger cohorts are clearly needed to understand the true incidence and nature of DKA in COVID-19.”

Recognition needed

For critically ill and medically complex patients, recognition and prompt treatment of DKA in the ICU setting is recommended, the researchers wrote. Preventing DKA is critically important when possible, which may include maintaining key clinical services using telemedicine and proactively delivering standard prevention advice to patients.

Clinicians should advise people with diabetes who become ill with COVID-19 to continue their home insulin regimen and reassess oral therapies when necessary. Insulin-deficient patients and those taking SGLT2 inhibitors should have ketone testing available to them at home should they develop illness, the researchers wrote.

“Patients experiencing hyperglycemia who are armed with ketone testing at home are better able to communicate with their care team on the severity of their illness when inpatient care is being considered,” the researchers wrote. “However, given the imprecision of point-of-care ketone testing, any patient who has elevated ketones detected by any means should be assessed for other signs of possible DKA, eg, nausea, vomiting and extreme thirst.”

In similar guidance published in June in The Journal of Clinical Endocrinology & Metabolism and reported by Healio, clinicians and diabetes care and education specialists recommended providers adapt protocols for optimal inpatient glycemic management during the COVID-19 pandemic as part of an effort to incorporate new therapies, limit direct patient contact and minimize infection risk. Recommendations addressed nontraditional insulin strategies, the effect of medications used to treat COVID-19, continuous glucose monitor use and self-management education.