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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024; 47:1257-1275. [PMID: 39052901 PMCID: PMC11272983 DOI: 10.2337/dci24-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 07/27/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.
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Affiliation(s)
- Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Georgia M. Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nuha A. ElSayed
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J. Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Irl B. Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
- University of Maryland Institute for Health Computing, Bethesda, MD
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, U.K
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, U.K
| | - Robert A. Gabbay
- American Diabetes Association, Arlington, VA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Ketan K. Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, U.K
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Umpierrez GE, Davis GM, ElSayed NA, Fadini GP, Galindo RJ, Hirsch IB, Klonoff DC, McCoy RG, Misra S, Gabbay RA, Bannuru RR, Dhatariya KK. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia 2024; 67:1455-1479. [PMID: 38907161 PMCID: PMC11343900 DOI: 10.1007/s00125-024-06183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 06/23/2024]
Abstract
The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Georgia M Davis
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nuha A ElSayed
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gian Paolo Fadini
- Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Rodolfo J Galindo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland Institute for Health Computing, Bethesda, MD, USA
| | - Shivani Misra
- Division of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Robert A Gabbay
- American Diabetes Association, Arlington, VA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
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Huang J, Yeung AM, Bergenstal RM, Castorino K, Cengiz E, Dhatariya K, Niu I, Sherr JL, Umpierrez GE, Klonoff DC. Update on Measuring Ketones. J Diabetes Sci Technol 2024; 18:714-726. [PMID: 36794812 PMCID: PMC11089855 DOI: 10.1177/19322968231152236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Ketone bodies are an energy substrate produced by the liver and used during states of low carbohydrate availability, such as fasting or prolonged exercise. High ketone concentrations can be present with insulin insufficiency and are a key finding in diabetic ketoacidosis (DKA). During states of insulin deficiency, lipolysis increases and a flood of circulating free fatty acids is converted in the liver into ketone bodies-mainly beta-hydroxybutyrate and acetoacetate. During DKA, beta-hydroxybutyrate is the predominant ketone in blood. As DKA resolves, beta-hydroxybutyrate is oxidized to acetoacetate, which is the predominant ketone in the urine. Because of this lag, a urine ketone test might be increasing even as DKA is resolving. Point-of-care tests are available for self-testing of blood ketones and urine ketones through measurement of beta-hydroxybutyrate and acetoacetate and are cleared by the US Food and Drug Administration (FDA). Acetone forms through spontaneous decarboxylation of acetoacetate and can be measured in exhaled breath, but currently no device is FDA-cleared for this purpose. Recently, technology has been announced for measuring beta-hydroxybutyrate in interstitial fluid. Measurement of ketones can be helpful to assess compliance with low carbohydrate diets; assessment of acidosis associated with alcohol use, in conjunction with SGLT2 inhibitors and immune checkpoint inhibitor therapy, both of which can increase the risk of DKA; and to identify DKA due to insulin deficiency. This article reviews the challenges and shortcomings of ketone testing in diabetes treatment and summarizes emerging trends in the measurement of ketones in the blood, urine, breath, and interstitial fluid.
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Affiliation(s)
| | | | | | | | - Eda Cengiz
- University of California San Francisco, San Francisco, CA, USA
| | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Isabella Niu
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - David C. Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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4
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Guarner J, Smith GH, Alter DN, Williams CJ, Cole L, Campbell DG, Elsea SM, Reynolds S, Lawrence C. Alternative Strategies to Provide Actionable Results When a Supply of Urinalysis Strips Is Unavailable. Arch Pathol Lab Med 2024; 148:e69-e74. [PMID: 37852173 DOI: 10.5858/arpa.2023-0217-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 10/20/2023]
Abstract
CONTEXT.— Urinalysis instrument-specific dip strips offer physicians qualitative results for actionable analytes (protein, glucose, leukocyte esterase, nitrates, hemoglobin, and ketones). OBJECTIVE.— To explain a strategy implemented to support clinical decision-making by providing urine quantification of protein, glucose, white blood cells (WBCs), and red blood cells because of urine strip shortages. DESIGN.— During shortages, we implemented an automated algorithm that triggered sending urine samples to the automation line for quantification of protein and glucose and ensured that urine microscopy was performed to obtain WBC and red blood cell counts. The algorithm printed 2 labels so nursing staff would collect 2 specimens. We monitored the turnaround time from the specimen being received in the laboratory to result verification, ensured that the culture reflex order was triggered, and tracked complaints by physicians regarding not having usual urinalysis results. Prior to implementation, correlation between sample types for protein and glucose measurement was found acceptable. RESULTS.— The algorithm was put in place twice during 2022. The turnaround time of urine microscopic study was identical to that obtained when the urinalysis was done with the strips; however, the quantification of glucose and protein took approximately 30 minutes more. Urine reflex cultures were triggered correctly with the algorithm, as they were derived entirely from a WBC count higher than 10 per high-power field. During the shortage period we had only 1 complaint, by a physician wanting to have results of nitrates. CONCLUSIONS.— During urine strip shortages, we successfully implemented a diversion algorithm that provided actionable urinalysis analytes in a timely manner with minimal provider complaints.
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Affiliation(s)
- Jeannette Guarner
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Geoffrey H Smith
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - David N Alter
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Cecellitha J Williams
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Lisa Cole
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Davette G Campbell
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Suzanne M Elsea
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Stacian Reynolds
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
| | - Christine Lawrence
- From the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia (Guarner, Smith, Alter); and Core Laboratories, Emory Healthcare, Atlanta, Georgia (Williams, Cole, Campbell, Elsea, Reynolds, Lawrence)
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Verdone M, Bauman J, Iversen E, Schulman-Rosenbaum R, Antonacci A, Leffe S, Simpson J, Harris YT, Marino J. Novel Approach to Continuation of Elective Procedures in People at Risk for Sodium-Glucose Cotransporter 2 Inhibitor-Associated Euglycemic Ketoacidosis. Diabetes Spectr 2024; 37:165-169. [PMID: 38756433 PMCID: PMC11093762 DOI: 10.2337/ds23-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Affiliation(s)
- Matthew Verdone
- Northwell, New Hyde Park, NY
- Endoscopic and Advanced Endoscopic Anesthesia Services, Long Island Center for Digestive Health, Northwell Health, Uniondale, NY
| | - Jonathan Bauman
- Northwell, New Hyde Park, NY
- Department of Anesthesiology, Northwell Health, New Hyde Park, NY
| | - Esben Iversen
- Northwell, New Hyde Park, NY
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Rifka Schulman-Rosenbaum
- Northwell, New Hyde Park, NY
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Northwell Health, New Hyde Park, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Anthony Antonacci
- Northwell, New Hyde Park, NY
- Lenox Hill Hospital, Northwell Health, New York, NY
| | - Sabatino Leffe
- Northwell, New Hyde Park, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
- South Shore University Hospital, Northwell Health, Bay Shore, NY
| | | | - Yael Tobi Harris
- Northwell, New Hyde Park, NY
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Northwell Health, New Hyde Park, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Joseph Marino
- Northwell, New Hyde Park, NY
- Department of Anesthesiology, Northwell Health, New Hyde Park, NY
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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O'Brolchain A, Maletsky J, Mian I, Edwards S. Does Treatment with Sodium-Glucose Cotransporter-2 Inhibitors Affect Adherence to International Society Criteria for Diabetic Ketoacidosis in Adult Patients with Type 2 Diabetes? A Retrospective Cohort Analysis. J Diabetes Res 2024; 2024:1849522. [PMID: 38516324 PMCID: PMC10957251 DOI: 10.1155/2024/1849522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 03/23/2024] Open
Abstract
Design Retrospective observational study. Setting. Inpatients at two teaching hospitals in Queensland, Australia. Primary Outcome Measure(s). The number of patients meeting the Joint British Diabetes Society (JBDS) and American Association of Clinical Endocrinology/American College of Endocrinology (AACE/ACE) diagnostic criteria for DKA. Patients were divided into two groups by treatment with SGLT2i at the time of diagnosis. Participants. Adult patients (>18 years old) with type 2 diabetes diagnosed with DKA from April 2015 to January 2022. Patients without type 2 diabetes were excluded. Results One hundred and sixty-five patients were included in this study-comprising 94 patients in the SGLT2i cohort and 70 in the non-SGLT2i cohort. A significantly smaller proportion of patients in the SGLT2i vs. non-SGLT2i cohorts met both JBDS (56% vs. 72%, p = 0.035) and AACE/ACE (63% vs. 82%, p = 0.009) criteria for diagnosis of DKA. Conclusion Patients with type 2 diabetes treated with SGLT2i may be more likely to be diagnosed with DKA despite not meeting the criteria. Despite recent adjustments to account the physiological effects of SGLT2i, significant variation in criteria between major society guidelines presents ongoing challenges to clinicians. The proportion of patients diagnosed using both JDBS and AACE/ACE were comparable, suggesting a reasonable degree of agreement.
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Affiliation(s)
- Aongus O'Brolchain
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
- Griffith University, Queensland, Australia
| | - Joshua Maletsky
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Ibrahim Mian
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Serena Edwards
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
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Subramanian S, Khan F, Hirsch IB. New advances in type 1 diabetes. BMJ 2024; 384:e075681. [PMID: 38278529 DOI: 10.1136/bmj-2023-075681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.
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Affiliation(s)
- Savitha Subramanian
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
| | - Farah Khan
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
| | - Irl B Hirsch
- University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
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Raiten JM, Morlok A, D'Ambrosia S, Ruggero MA, Flood J. Perioperative Management of Patients Receiving Sodium-Glucose Cotransporter 2 Inhibitors: Development of a Clinical Guideline at a Large Academic Medical Center. J Cardiothorac Vasc Anesth 2024; 38:57-66. [PMID: 37932195 DOI: 10.1053/j.jvca.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/08/2023]
Abstract
The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology, and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.
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Affiliation(s)
- Jesse M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Andrea Morlok
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah D'Ambrosia
- Center for Evidence Based Practice, University of Pennsylvania, Philadelphia, PA
| | - Michael A Ruggero
- Department of Pharmacy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jeremy Flood
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Kilpatrick ES, Butler AE, Saeed S, Alamuddin N, Atkin SL, Sacks DB. The effectiveness of blood glucose and blood ketone measurement in identifying significant acidosis in diabetic ketoacidosis patients. Diabetol Metab Syndr 2023; 15:198. [PMID: 37828619 PMCID: PMC10571296 DOI: 10.1186/s13098-023-01176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Patients with diabetic ketoacidosis (DKA), a potentially fatal complication of type 1 diabetes, have hyperglycemia, ketonemia and metabolic acidosis. Blood glucose and blood ketone results are often used to triage patients with suspected DKA. This study aimed to establish how effective blood glucose and blood ketone (beta-hydroxybutyrate, BOHB) measurements are in identifying patients with significant acidosis and sought to validate existing diagnostic BOHB thresholds. METHODS Initial Emergency Department results on 161 presumptive DKA episodes in 95 patients (42 F, 53 M, age range 14-89 years) containing a complete dataset of D (glucose), K (BOHB) and A (Bicarbonate [HCO3] and pH) results. RESULTS Blood glucose correlated poorly with BOHB (r = 0.28 p = 0.0003), pH (r= -0.25, p = 0.002) and HCO3 (r= -0.17, p = 0.04). BOHB, though better, was still limited in predicting pH (r = -0.44, p < 0.0001) and HCO3 (r = -0.49, p < 0.0001). A HCO3 of 18mmol/L equated to a BOHB concentration of 4.3mmol/L, whilst a HCO3 of 15mmol/L equated to a BOHB of 4.7mmol/L. Of the 133 of 161 events with HCO3 < 18mmol/L, 22 were not hyperglycemic (> 13.9mmol/L, n = 8), ketonemic (≤ 3mmol/L, n = 9) or either (n = 5). CONCLUSIONS The commonly employed BOHB diagnostic cutoff of 3mmol/L could not be verified. Since acid-base status was poorly predicted by both glucose and BOHB, this highlights that, regardless of their results, pH and/or HCO3 should also be tested in any patient suspected of DKA.
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Affiliation(s)
| | - Alexandra E Butler
- Department of Postgraduate Studies and Research, Royal College of Surgeons in Ireland, PO Box 15503, Busaiteen, Adliya, Bahrain.
| | - Sawsan Saeed
- Department of Postgraduate Studies and Research, Royal College of Surgeons in Ireland, PO Box 15503, Busaiteen, Adliya, Bahrain
| | - Naji Alamuddin
- Department of Medicine, Royal College of Surgeons in Ireland, PO Box 15503, Busaiteen, Adliya, Bahrain
- Department of Internal Medicine, King Hamad University Hospital, Busaiteen, Adliya, Bahrain
| | - Stephen L Atkin
- Department of Postgraduate Studies and Research, Royal College of Surgeons in Ireland, PO Box 15503, Busaiteen, Adliya, Bahrain
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10
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Diabetes Care 2023; 46:e151-e199. [PMID: 37471273 PMCID: PMC10516260 DOI: 10.2337/dci23-0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/11/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B. Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA
| | - George L. Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, IL
| | - David E. Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA
| | - Andrea R. Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E. Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL
| | - David M. Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - M. Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC
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11
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Clin Chem 2023:hvad080. [PMID: 37473453 DOI: 10.1093/clinchem/hvad080] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA, United States
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, ILUnited States
| | - David E Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA, United States
| | - Andrea R Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL, United States
| | - David M Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
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12
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Kilpatrick ES. New Laboratory Guidelines for Diabetes: Continuing the Collaboration between Clinical and Laboratory Medicine. Clin Chem 2023:hvad092. [PMID: 37473456 DOI: 10.1093/clinchem/hvad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Eric S Kilpatrick
- Division of Clinical Biochemistry, Sidra Medicine, Doha, Qatar and Weill Cornell Medicine-Qatar, Doha, Qatar
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13
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Tremblay ES, Millington K, Wu Y, Wypij D, Yang Y, Agus MS, Wolfsdorf J. Utility of plasma beta-hydroxybutyrate to define resolution of diabetic ketoacidosis. Pediatr Diabetes 2022; 23:1621-1627. [PMID: 36268546 PMCID: PMC9772128 DOI: 10.1111/pedi.13437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a common, life-threatening complication of type 1 diabetes (T1D) characterized by unregulated ketogenesis caused by relative or absolute insulin deficiency. DKA management requires frequent biochemical monitoring. Plasma ß-hydroxybutyrate (BOHB) has not been included in traditional definitions of DKA resolution. OBJECTIVE The aim of this study was to determine a cut-point level of BOHB to define DKA resolution in patients with T1D treated with intravenous (IV) insulin. SUBJECTS We identified patients with T1D receiving IV insulin for DKA treatment at a quaternary children's hospital from January 1, 2017 through December 31, 2020 who had plasma measurements of BOHB after DKA onset and whose DKA resolved by traditional laboratory criteria (venous pH (vpH) ≥ 7.3, serum bicarbonate (HCO3 ) ≥ 15 mmol/L, and/or anion gap (AG) ≤ 14 mmol/L). METHODS Associations between plasma BOHB and vpH, HCO3 , and AG were evaluated via scatterplots. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were used to evaluate BOHB cut-points to predict DKA resolution. RESULTS We analyzed 403 patients with 471 unique encounters. Plasma BOHB showed the most robust relationship with AG. The ROC curve comparing plasma BOHB to the accepted definition of DKA resolution, AG ≤14 mmol/L, had an AUC of 0.92. A BOHB value of <1.5 mmol/L had a sensitivity of 83% and specificity of 87%; this cut-point correctly classified 86% of the observations. CONCLUSIONS A plasma BOHB value of <1.5 mmol/L can be used to define resolution of DKA.
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Affiliation(s)
- Elise Schlissel Tremblay
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kate Millington
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Yunhong Wu
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - David Wypij
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yufan Yang
- Feinberg School of Medicine, Northwestern University
| | - Michael S.D. Agus
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Medical Critical Care, Boston Children’s Hospital, Boston, Massachusetts
| | - Joseph Wolfsdorf
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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14
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Huang J, Yeung AM, Nguyen KT, Xu NY, Preiser JC, Rushakoff RJ, Seley JJ, Umpierrez GE, Wallia A, Drincic AT, Gianchandani R, Lansang MC, Masharani U, Mathioudakis N, Pasquel FJ, Schmidt S, Shah VN, Spanakis EK, Stuhr A, Treiber GM, Klonoff DC. Hospital Diabetes Meeting 2022. J Diabetes Sci Technol 2022; 16:1309-1337. [PMID: 35904143 PMCID: PMC9445340 DOI: 10.1177/19322968221110878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood glucose targets, (3) software for inpatient diabetes, (4) surgery, (5) transitions, (6) coronavirus disease and diabetes in the hospital, (7) drugs for diabetes, (8) continuous glucose monitoring, (9) quality improvement, (10) diabetes care and educatinon, and (11) uniting people, process, and technology to achieve optimal glycemic management. This meeting covered new technology that will enable better care of people with diabetes if they are hospitalized.
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Affiliation(s)
| | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Umesh Masharani
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | | | | | | | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Diabetes Research Institute, Mills-Peninsula Medical Center, 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
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15
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Exogenous Ketone Supplements in Athletic Contexts: Past, Present, and Future. Sports Med 2022; 52:25-67. [PMID: 36214993 PMCID: PMC9734240 DOI: 10.1007/s40279-022-01756-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 12/15/2022]
Abstract
The ketone bodies acetoacetate (AcAc) and β-hydroxybutyrate (βHB) have pleiotropic effects in multiple organs including brain, heart, and skeletal muscle by serving as an alternative substrate for energy provision, and by modulating inflammation, oxidative stress, catabolic processes, and gene expression. Of particular relevance to athletes are the metabolic actions of ketone bodies to alter substrate utilisation through attenuating glucose utilisation in peripheral tissues, anti-lipolytic effects on adipose tissue, and attenuation of proteolysis in skeletal muscle. There has been long-standing interest in the development of ingestible forms of ketone bodies that has recently resulted in the commercial availability of exogenous ketone supplements (EKS). These supplements in the form of ketone salts and ketone esters, in addition to ketogenic compounds such as 1,3-butanediol and medium chain triglycerides, facilitate an acute transient increase in circulating AcAc and βHB concentrations, which has been termed 'acute nutritional ketosis' or 'intermittent exogenous ketosis'. Some studies have suggested beneficial effects of EKS to endurance performance, recovery, and overreaching, although many studies have failed to observe benefits of acute nutritional ketosis on performance or recovery. The present review explores the rationale and historical development of EKS, the mechanistic basis for their proposed effects, both positive and negative, and evidence to date for their effects on exercise performance and recovery outcomes before concluding with a discussion of methodological considerations and future directions in this field.
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