Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review

Abstract

Objectives: To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration).

Design: Systematic literature review (SLR).

Data sources: Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016).

Study selection: Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised.

Results: Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0-56 per 1000 person-years (PYs), with one outlying study reporting an incidence of 263 per 1000 PYs. Eleven studies reported prevalence with a range of 0-128 per 1000 people. Prevalence of DKA decreased with increasing age. Subgroup analyses were performed using data from no more than two studies per subgroup. There was a higher prevalence of DKA reported in women, non-whites and patients treated with insulin injections compared with men, whites and patients using continuous subcutaneous insulin infusion pumps, respectively.

Conclusions: To our knowledge, this is the first SLR on the epidemiology of DKA in T1D adults. Despite an increasing prevalence of T1D in recent years, DKA in adults has been poorly characterised. In an era when the benefit-risk profiles of new antidiabetic therapies are being evaluated, including the potential risk of DKA, there is a clear need to better elucidate the expected rate of DKA among T1D adults.

Keywords: diabetic ketoacidosis; epidemiology; incidence; prevalence; systematic literature review; type 1 diabetes mellitus.

Figure 1

Literature selection and review process. Submitted as image. Footnotes. Key search terms: Type 1 diabetes; adult; diabetic ketoacidosis. SLR, systematic literature review; T1D, type 1 diabetes mellitus.

Figure 2

Incidence rate per 1000 PY of DKA in adults with T1D (reported in eight studies). Submitted as image. Footnotes. *Calculated value based on data contained within publication. †Patients who initiated CSII within 1 year of diagnosis, aged >19 years at CSII initiation. ‡Patients who initiated CSII within 1 year of diagnosis, aged >19 years at last visit. ‖Conventional treatment arm from DCCT. §Intensive treatment arm from DCCT. ¶Patients who initiated CSII at least 1 year postdiagnosis, aged >19 years at CSII initiation. **Patients who initiated CSII at least 1 year postdiagnosis, aged >19 years at last visit. CSII, continuous subcutaneous insulin infusion; DCCT, Diabetes Control and Complications Trial; DKA, diabetic ketoacidosis; DPV, Diabetes-Patienten-Verlaufsdokumentation; EDC, epidemiology of diabetes complications; EDIC, epidemiology of diabetes interventions and complications; F/U, follow-up; PY, person-years; T1D, type 1diabetes mellitus; UK, United Kingdom; USA, United States of America; yr, year.

Figure 3

Prevalence (per 1000 people) of DKA in adults with T1D (reported in 11 studies). Submitted as image. Footnotes. *CGM non-user. †Calculated value based on data contained within publication. ‡CGM user. §Overall study population. ǁDefinite T1D. CGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infusion; DKA, diabetic ketoacidosis; HbA1c, glycosylated haemoglobin; MDI, multiple daily injection; NR, not reported; T1D, type 1 diabetes mellitus; yrs, years.