COVID-19 associated with hyperglycaemic emergencies and Keto
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Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are hyperglycaemic emergencies associated with substantial mortality. To date there is paucity of data on the characteristics of hyperglycaemic emergencies occurring in the context of COVID-19.

This retrospective analysis recruited eligible patients from three hospitals in north London, UK. 35 patients with COVID-19, presenting with DKA, mixed DKA and HHS, HHS, or hyperglycaemic ketosis were included and evaluated. Type 2 diabetes was prevalent in 28, whereas 2 of 35 patients were new presentation of diabetes. Previous history of DKA was found in 5 patients with type 1 disease. Median overall HbA1c was 111 mmol/mol.

Before hospital admission 12 of 35 of patients were on insulin treatment. Two patients were on SGLT2 inhibitor treatment and presented with mixed DKA and HHS.

Median time to ketone resolution for patients with DKA was 35 h. Severe insulinopenia persisted until discharge for 7 of 35 patients, previously non-insulin treated. At the time of this report, 13 were still inpatients, whereas 2 of 35 patients, previously non-insulin treated, had died.

Conclusions:
-- This study shows striking type 2 disease overrepresentation in those presenting with DKA, suggesting acute insulinopenia in patients with COVID-19 and with type 2 diabetes, which persisted up until the time of discharge in 30% of patients previously not insulin-treated.
-- The patients developed protracted ketonaemia and ketoacidosis, with median time to ketone resolution in DKA of approximately 35 h; whereas in non-COVID-19 DKA cases the median duration of ketoacidosis is approximately 12 h.
-- Emerging reports suggest substantial insulin resistance and possibly relative insulinopenia in severe COVID-19 disproportionate to that seen in critical illness caused by other conditions, which might have contributed to the metabolic decompensation.
-- In line with these observations, 35% of patients in this study required an increase of the fixed dose insulin infusion above the recommended insulin dose for DKA of 0·1 units/kg per h.

Source: https://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(20)30221-7.pdf
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