Practice Update: DIABETES

CONFERENCE COVERAGE 12

BMI, polypharmacy, lab testingmay help diagnose DKA and identify high risk of its recurrence Demographic variables, especially body mass index and polypharmacy, could potentially aid in identifying subjects at high risk of recurrent diabetic ketoacidosis. In addition, beta-hydroxybutyrate measurement adds rigor to the diagnosis of diabetic ketoacidosis, conclude two presentations on diagnosing diabetic ketoacidosis and risk factors for its recurrence. V ishal Sehgal, MD, of the University of Tennessee Health Science Center, Memphis, explained, “Diabetic variables. Multivariable logistic regression was used to determine predictors of recur- rent diabetic ketoacidosis. variables, especially body mass index and polypharmacy, could potentially aid in identifying subjects at high risk of recurrent diabetic ketoacidosis.

ketoacidosis and its recurrence continue despite near-universal availability of insulin. So we set out to describe factors associ- ated with recurrent diabetic ketoacidosis in a community hospital.” He added, “The cost of healthcare seems to rise every year with no corresponding improvement in healthcare statistics. In this context, any scientific study should focus on reducing healthcare costs, in addition to reducing the morbidity and mortality.” All patients admitted with the diagnosis of diabetic ketoacidosis from 2013 to 2015 were identified. Patients with multiple admissions were identified and compared with patients who were admitted for dia- betic ketoacidosis only once. The unadjusted association between each of the variables and diabetic ketoacidosis was determined using chi-square tests for categorical variables and t-tests for con- tinuous variables. Logistic regression was used to calculate odds ratios and 95% confidence intervals for all categorical

A total of 116 patients accounted for 349 admissions during the 33-month study period. Of the 116 patients with diabetic ketoacidosis, 58 experienced only one episode and the remainder were admit- ted multiple times. Unadjusted results suggested that patients with lower body mass index, mean body weight and higher anion gap values were more likely to suffer recurrent diabetic ketoacidosis. In multivariable analysis, how- ever, body mass index and polypharmacy were the strongest predictors of recurrent diabetic ketoacidosis. Low body mass index and polypharmacy are easily quantifiable in day-to-day clin- ical practice. The results provide simple and easily available markers of patients at high risk of recurrent diabetic ketoacidosis. If confirmed in other data sets and pop- ulations, these markers might help direct interventions toward high-risk patients to reduce their morbidity and mortality. Dr Sehgal concluded that demographic

He said, “Our study helped define two easily quantifiable markers of readmis- sion to hospital in patients with diabetic ketoacidosis. Such identification could be extrapolated to hospital readmissions for other disease pathologies as well.” He continued, “If validated in other studies, interventions may be designed to reduce hospital readmissions in this population. Such interventions could help save the healthcare system billions of dollars.” In a related study on diabetic ketoacidosis presented at the American College of Clin- ical Endocrinology’s Scientific and Clinical Congress, John M. Miles, MD, FACE, of the University of Kansas Medical Center, Kan- sas City, assessed diagnostic criteria for the disorder. Dr Miles explained that American Diabetes Association diagnostic criteria for diabetic ketoacidosis include the triad of ketonuria, hyperglycemia (glucose ≥250 mg/dL), and serum bicarbonate ≤18 mEq/L. Serum bicarbonate is not specific for dia- betic ketoacidosis, however, and American Diabetes Association recommendations on laboratory testing for diabetes state that urine ketone testing should not be used for diagnosing diabetic ketoacidosis in view of its qualitative nature and inability to detect the dominant ketone body anion in diabetic ketoacidosis, beta-hydroxybutyrate. In a prior study, these limitations led Dr Miles and coinvestigators to suggest that admission beta-hydroxybutyrate ≥3.8 mmoL/L could be used in place of these criteria to diagnose diabetic ketoacidosis. In the present study, Dr Miles’s team reviewed records from adult admissions for diabetic ketoacidosis from 2012–2016 to assess the sensitivity and specificity of the American Diabetes Association criteria, using beta-hydroxybutyrate ≥3.8 mmoL/L to define diabetic ketoacidosis. Trace or negative ketonuria was consid- ered to be inconsistent with a diagnosis of diabetic ketoacidosis, whereas small, moder- ate, or large ketones were considered to be

© Photo by Jean Whiteside/AACE 2017

PRACTICEUPDATE DIABETES