Autoantibodies to the IA-2 Extracellular Domain Refine the Definition of "A+" Subtypes of Ketosis-Prone Diabetes

Characterizing progressive beta-cell recovery after new-onset DKA in COVID-19 provoked A-β+ KPD (ketosis-prone diabetes): A prospective study from Eastern India

BACKGROUND

Recent literature suggests a bi-directional relationship between COVID-19 infection and diabetes mellitus, with an increasing number of previously normoglycemic adults with COVID-19 being admitted with new-onset diabetic ketoacidosis (DKA). However, the possibility of COVID-19 being a potential trigger for A-β + ketosis-prone diabetes (KPD) in these patients needs elucidation. Our study aimed at analyzing such a cohort of patients and determining their natural course of β-cell recovery on serial follow-up.

METHODS

After initial screening, n = 42 previously non-diabetic patients with new-onset DKA and RT-PCR positive COVID-19, were included in our ten-month follow-up study. Of these, n = 22 were negative (suspected A-β + KPD) and n = 20 were positive (Type 1A DM) for autoantibodies (GAD/IA-2/ZnT8). Subsequently, n = 19 suspected KPD and n = 18 Type 1A DM patients were followed-up over ten months with serial assessments of clinical, biochemical and β-cell secretion. Amongst the former, n = 15 (79%) patients achieved insulin independence, while n = 4 (21%) continued to require insulin at ten-months follow-up.

RESULTS

On comparison, the suspected KPD patients showed significantly greater BMI, age, Hba1c, IL-6 and worse DKA parameters at presentation. Serial C-peptide estimations demonstrated significant β-cell recovery in KPD group, with complete recovery seen in the 15 patients who became insulin independent on follow-up. Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were associated with poorer recovery of β-cell secretion at ten-month follow-up amongst the KPD patients, CONCLUSIONS: This is the first prospective study to demonstrate progressive recovery of β-cell secretion in new-onset A-β + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM. Given their significant potential for β-cell recovery, meticulous follow-up involving C-peptide estimations can help guide treatment and avoid injudicious use of insulin.

Establishing reference intervals for islet autoantibodies in Han Chinese type 1 diabetes

Currently, islet autoantibodies (IAbs) constitute the most reliable marker for detecting the autoimmune process of type 1 diabetes (T1D). However, there are no appropriate reference intervals (RIs) to interpret the results of IAbs in China. In this study, we aimed to establish the RIs of four common IAbs based on the Han Chinese population and evaluate their clinical diagnostic values in patients with T1D. We collected 177 blood samples from healthy volunteers to detect the levels of IAbs directed against insulin (IAA), glutamic acid decarboxylase-65 (GADA), insulinoma antigen 2 (IA-2A), and zinc transporter-8 (ZnT8A) using a chemiluminescence immunoassay. RIs were calculated using nonparametric 95th percentile intervals in accordance with the Clinical and Laboratory Standards Institute guidelines, and their clinical diagnostic values were evaluated by detecting the levels of IAbs of 140 blood samples from patients with T1D in a clinical setting. We defined 138 individuals as the apparently healthy population from the 177 healthy volunteers based on the exclusion criteria. No association between the levels of the four IAbs and gender (p > .05) and age (p > .05) were found in the apparently healthy population. The combined RIs for GADA, IA-2A, ZnT8A, and IAA were 0-1.78 IU/mL, 0-3.91 IU/mL, 0-2.36 AU/mL, and 0-0.58 COI, respectively. Overall, the diagnostic efficiency for the four IAbs, especially for GADA and IAA, were improved by using the RIs established in this study. The RIs for IAbs established in this study will be a valuable tool for disease diagnosis and the therapeutic management of T1D in a clinical setting.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

Clinical guidelines for type 1 diabetes mellitus with an emphasis on older adults: an Executive Summary

We present a summary of a guideline produced by an international group of experts for managing type 1 diabetes in adults with an emphasis on the special needs of older people with this condition. The rationale for delivering high-quality diabetes care for adults with type 1 diabetes, why it is important to include older people in our considerations, and the key underpinning principles of the guideline are included. The structure of the recommendations given is described and consists of 'general' recommendations followed by 'specific' recommendations according to three categories depending on the characteristics of adults addressed, such as functional level or self-management ability. Recommendations are provided in the areas of: clinical diagnosis, establishing management plans and glucose regulation, diabetes self-management education, nutritional therapy, physical activity, exercise and lifestyle modification, insulin treatments and regimens, use of technology in diabetes management, hypoglycaemia, managing cardiovascular risk, management of microvascular risk, and inpatient management of type 1 diabetes and ketoacidosis.

SGLT2 Inhibitors Increase the Risk of Diabetic Ketoacidosis Developing in the Community and During Hospital Admission

CONTEXT

Diabetic ketoacidosis (DKA) has been associated with the use of sodium glucose cotransporter 2 inhibitors (SGLT2is).

OBJECTIVE

To determine the incidence, characteristics, and outcomes of DKA in SGLT2i users vs nonusers with type 2 diabetes.

DESIGN

Retrospective, multicenter, controlled cohort study.

SETTING

All public hospitals in Melbourne and Geelong (combined population of 5 million), Australia, from 1 September 2015 to 31 October 2017.

PATIENTS

Consecutive cases of DKA that developed in the community, or during the course of hospital admission, in patients with type 2 diabetes.

MAIN OUTCOME MEASURES

In SGLT2i users vs nonusers: (i) OR of DKA developing during hospital admission, and (ii) incidence of DKA.

RESULTS

There were 162 cases of DKA (37 SGLT2i users and 125 non-SGLT2i users) with a physician-adjudicated diagnosis of type 2 diabetes. Of these, DKA developed during the course of inpatient admission in 14 (38%) SGLT2i users vs 2 (2%) non-SGLT2i users (OR, 37.4; 95% CI, 8.0 to 175.9; P < 0.0001). The incidence of DKA was 1.02 per 1000 (95% CI, 0.74 to 1.41 per 1000) in SGLT2i users vs 0.69 per 1000 (95% CI, 0.58 to 0.82 per 1000) in non-SGLT2i users (OR, 1.48; 95% CI, 1.02 to 2.15; P = 0.037). Fifteen SGLT2i users (41%) had peak blood glucose <250 mg/dL (14 mmol/L) compared with one (0.8%) non-SGLT2i user (P < 0.001).

CONCLUSIONS

SGLT2i users were more likely to develop DKA as an inpatient compared with non-SGLT2i users. SGLT2i use was associated with a small but significant increased risk of DKA.