Diabetic Ketoacidosis in COVID-19: Unique Concerns and Considerations

Abstract

Context: While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign.

Case description: This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach.

Conclusions: As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.

Keywords: diabetes; diabetic ketoacidosis; pancreatic and gastrointestinal hormones.

Figure 1.

Conceptual framework of the pathophysiology of diabetic ketoacidosis. In DKA, insulin insufficiency sets off a cascade of maladaptive physiologic responses including formation of excessive ketone bodies leading to metabolic acidosis, and hyperglycemia resulting in progressive hypovolemia and electrolyte loss. In the setting of inflammatory illness, cytokines and other factors drive this process. IL-6 levels have been shown to be elevated in both DKA and COVID-19, and may be an important prognostic factor. FFA, free fatty acids; TNFα, tumor necrosis factor α; IL-6, interleukin 6; IL-1β, interleukin 1β.