DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES

Abstract

Objective: More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes.

Methods: We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes.

Results: In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy.

Conclusion: KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes.

Abbreviations: A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.

Fig. 1

Cox proportional hazards of failure-free survival between metformin, sitagliptin, and placebo in obese African American patients presenting with diabetic ketoacidosis and severe hyperglycemia. There was a significant difference was found between the placebo, metformin, and sitagliptin groups (P =.015) but not between the sitagliptin and metformin groups (P =. 75) (copyright, American Diabetes Association, Diabetes Care).