Is acid suppression associated with the increased length of stay in diabetic ketoacidosis patients? A nationwide analysis

Abstract

Background: Diabetic ketoacidosis (DKA) patients present with low serum bicarbonate ( ${\mathrm{HCO}}_3^{-}$ ), and an increase in its level to ≥15 mEq/L is considered one of the criteria for DKA resolution. Both proton pump inhibitors and histamine-2 receptor antagonists inhibit downstream functioning of H⁺ /K⁺ ATPase in the gastric parietal cells, which results in the decreased secretion of ${\mathrm{HCO}}_3^{-}$ into the bloodstream.

Objectives: We aimed to introduce the hypothesis that DKA patients on acid-suppressive medications may have a delayed rise in serum ${\mathrm{HCO}}_3^{-}$ to >15 mEq/L that may cause increased hospital length of stay (LOS) and sought to compare the outcomes of such patients. For the sake of simplicity, conditions requiring acid suppression are grouped under the term peptic ulcer disease (PUD) in this study.

Methods: This is a retrospective study using Nationwide Inpatient Sample employing International Classification of Diseases (ICD-10) codes for adult patients with a primary diagnosis of DKA. Analyses were performed using STATA, proportions were compared using Fisher exact test, and continuous variables using Student's t-test. Confounding variables were adjusted using propensity matching, multivariate logistic, and linear regression analyses.

Results: DKA patients with PUD had higher adjusted LOS, intensive care unit admission, and total hospital costs. Mortality and morbidity indicators were similar in both groups. The variables found to be independent predictors of increased LOS were malnutrition, Clostridium difficile infection, pneumonia, Glasgow Coma Scale score of 3-8, and higher Charlson comorbidity score.

Conclusion: We found that Clostridium difficile and pneumonia predicted longer LOS in DKA patients with concomitant PUD, hinting at the possible role of acid suppression in prolonging the LOS in such patients. However, further studies are needed to examine the effect of lesser ${\mathrm{HCO}}_3^{-}$ generation on LOS.

Keywords: histamine H2 blockers; hospital costs; length of stay; morbidity; mortality; proton pump Inhibitors.

Fig. 1

Patient selection flow diagram (DKA, diabetic ketoacidosis; PUD, peptic ulcer disease).