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Review
. 2023 Jul 26:14:1234256.
doi: 10.3389/fendo.2023.1234256. eCollection 2023.

Uncovering the alarming rise of diabetic ketoacidosis during COVID-19 pandemic: a pioneer African study and review of literature

Asma Gorchane  1   2 , Taieb Ach  1   2   3 , Jihene Sahli  2   4 , Asma Ben Abdelkrim  1   2 , Manel Mallouli  2   4 , Foued Bellazreg  2   5 , Wissem Hachfi  2   5 , Molka Chadli Chaieb  1   2 , Koussay Ach  1   2
Affiliations
Review

Uncovering the alarming rise of diabetic ketoacidosis during COVID-19 pandemic: a pioneer African study and review of literature

Asma Gorchane et al. Front Endocrinol (Lausanne). .

Abstract

Introduction: Reports around the world indicate that COVID-19 pandemic may be contributing to an increase in the incidence of new onset diabetic ketoacidosis (DKA). This has yet to be studied in Africa. We aimed to compare the incidence trend of new onset DKA before and during the COVID-19 pandemic, with a focus on the type of diabetes mellitus (DM).Materials and methodsThis was a cross sectional analytical study, over a 4-year period, between March 2018 until February 2022 conducted in the referral center: diabetology department of university hospital Farhat Hached Sousse, Tunisia. The study population included patients hospitalized for new onset DKA divided in two groups: G1: before COVID-19 pandemic and G2: during COVID-19 pandemic. Patients younger than 14, new onset DM not presenting with DKA, other types of diabetes (monogenic, secondary or pancreatic diabetes) were not included. A statistical analysis of the monthly incidence trend was conducted using the Jointpoint software providing the average monthly percentage of change (AMPC).

Results: a total of 340 patients were included:137 registered before the pandemic and 203 during the pandemic, representing a 48.17% increase. The mean monthly incidence of new onset DKA during COVID-19 pandemic was statistically higher than that before COVID-19 pandemic (8.42 ± 4.87 vs 5.75 ± 4.29 DKA per month) (p=0.049). The temporal trend of DKA during the 4-year study showed a significant upward trend with a change in AMPC of +0.2% (p=0.037). The incidence of type 1 diabetes (T1D) and type 2 diabetes (T2D) increased by 50% and 44% respectively during COVID-19 pandemic. Anti-glutamic acid decarboxylase (anti-GAD) antibodies' titers significantly increased in G2 compared with G1 (median of 330[Q1-Q3]=[58.5-1795]vs 92.5[Q1-Q3]=[22.5-1074] respectively)(p=0.021).

Discussion: The incidence trend of DKA showed an increase during the COVID-19 pandemic along with an increase of T1D and T2D implying that the pandemic may have been the underlying factor of this upward trend.

Keywords: COVID-19; diabetic ketoacidosis; epidemiology; type 1 diabetes; type 2 diabetes.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Temporal trend of hospital DKA between March 2018 and February 2022: it shows a significant upward trend with a change in the average monthly percent change (AMPC) of +0.2%, with p=0.037.
Figure 2
Figure 2
Incidence of DKA during COVID-19 according to pandemic waves: it shows a decrease during the third wave with a re-increase during the fourth and fifth waves.
Figure 3
Figure 3
Distribution of diabetes type before (GI) and during COVID-19 (G2). The incidence of TID increased by 50% during COVID-19 pandemic as 54 (38.42%) out of 137 patients were TID in G1 vs 81 (40.30%) out of 201 patients in G2 while the incidence of T2D increased by 44% as 83 (60.58%) out of 137 patients were T2D in GI vs 120 (59.70%) out of 201 patients in G2. However, the distribution of TID and T2D frequencies was comparable between the two groups (p=0.871).
Figure 4
Figure 4
Comparison of antibodies' titers before (GI) and during COVID-19 (G2). This graphical representation provides a comparison of anti-glutamic acid decarboxylase (anti-GAD) and anti-islet cell antigen (anti-IA2) titers before and during the COVID-19 pandemic. The data reveals a statistically significant increase in anti-GAD titers during COVID-19 (GI) compared to the prepandemic period (p=0.021). Furthermore, it demonstrates a significant elevation in anti-IA2 titers during COVID-19 (G2) in contrast to the prepandemic period (p=0.009).
Figure 5
Figure 5
Comparison of main precipitating factors of DKA before (GI) and during COVID-19 pandemic in patients with new onset T2D (G2); the distribution of DKA precipitating factors in T2D differed significantly between the two groups (p=0.003) with a notable increase of stress (29.7% in G2 vs 17.1% in GI, AR-2) as well as excessive food intake notably hypertonic drinks (10.2% in G2 vs 3.7% in G1) at the expense of corticosteroid use as its accountability in precipitating DKA significantly decreased in G2 (2.5% in G2 vs 9.8% in GI, AR-2.2). The infectious precipitating factors remained comparable between the two groups (30.5% in G1 vs 36.4%, AR-0.9).
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