It may be possible to identify patients with diabetes, both type 1 and type 2, at risk of developing life-threatening hyperglycemic crises of diabetic ketoacidosis or hyperglycemic hyperosmolar state, suggests a new study from the United States, published in JAMA Network Open on Wednesday.

The study, which included 20,156 adults with type 1 diabetes and 796,382 with type 2 diabetes, evaluated the association of sociodemographic factors (such as age, sex, race/ethnicity, region and income), clinical factors (such as comorbid conditions) and treatment-related factors (such as HbA1c, antihyperglyemic drugs) with hyperglycemic crises in these patients.

Factors like low income, Black race/ethnicity, high HbA1c level, history of hyperglycemic crises, severe hypoglycemia, depression, neuropathy and nephropathy were found to be associated with increased risk of hyperglycemic crises.

Among these factors, the strongest association was observed for past history of diabetic ketoacidosis and hyperglycemic hyperosmolar state. The risk for another episode of hyperglycemic crisis was 8-folds higher in patients with type 1 diabetes (incidence risk ratio [IRR] 7.88); an alarming observation was the 18-fold greater risk of occurrence of one more episode of hyperglycemic crisis (IRR 17.51).

The risk of hyperglycemic crises was increased 7-times in patients with poorly controlled diabetes (both type 1 and type 2) with A1c ≥10% as opposed to those patients in whom the A1c ranged from 6.5% to 6.9% (IRR 7.81 for type 1 diabetes vs IRR 7.06 for type 2 diabetes).

Severe hypoglycemia was also found to be predictive of a hyperglycemic crisis. The IRR for hyperglycemic crises was 2.77 for patients with type 1 diabetes and 4.18 for patients with type 2 diabetes.

The incidence of hyperglycemic crisis was higher in type 2 diabetes patients with comorbid heart failure, COPD, cerebrovascular disease, retinopathy, peripheral vascular disease, cirrhosis, dementia or cancer. No such association was observed for patients with type 1 diabetes. The risk was also higher in patients with type 2 diabetes being treated with sodium-glucose co-transporter-2 (SGLT2) inhibitors or were insulin dependent.

When sociodemographic factors were evaluated, patients with low annual income were found to be more vulnerable to develop  diabetic ketoacidosis or hyperglycemic hyperosmolar state, a finding which highlights the need to make treatment affordable and accessible to all patients. High income was defined as ≥$200,000 and low income was ≤$40,000 for this study.

Diabetes has an impact on almost all organs of the body and so requires multidisciplinary care for optimal management. This study has identified multiple factors that may identify patients at high risk of developing diabetic ketoacidosis or hyperglycemic hyperosmolar state, which are a preventable complication, but also potentially life-threatening. These factors also point out the need for timely multidisciplinary intervention to reduce the incidence of hyperglycemic crisis and also to educate patients about diabetes self-management.

(Source: McCoy RG, et al. Sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises among adults with type 1 or type 2 diabetes in the US from 2014 to 2020. JAMA Netw Open 2021; DOI: 10.1001/jamanetworkopen.2021.23471; Medpage Today, September 1, 2021)