COVID-19 appeared to increase risk of mortality in people hospitalized with diabetic ketoacidosis (DKA), researchers reported.

In a comparison of hospitalized DKA patients from February to September 2020, 30% of those who also had COVID-19 died in the hospital, as compared with 5% of those who didn’t have COVID-19, reported Francisco Pasquel, MD, MPH, of Emory University School of Medicine in Atlanta, and colleagues.

In-hospital mortality also varied according to age, they stated in a research letter in JAMA Network Open. For patients over 65, inpatient mortality was 45% for those with COVID-19 versus 13% without. In patients younger than 45, these rates were 19% versus 2%, respectively.

Patients with COVID-19 had a three times higher rate of acute kidney injury during an episode of DKA, at 30% versus 10% among those without COVID-19, the authors reported.

“Several transformations in diabetes care are occurring during the COVID-19 pandemic to reduce the number of patient interactions,” Pasquel’s group pointed out. “However, it is not known whether fewer interactions may increase mortality by causing a delay in DKA resolution.”

The researchers stated that they don’t exactly know what the root cause of this higher mortality rate in the COVID-19-positive population with DKA is, but called it “worrisome” and an issue that needs more investigation. However, they suggested that contributing factors may include obesity and a more severe state of stress that requires more insulin.

The cohort study included data from the Glytec national database of patients from 175 hospitals across 17 states. A total of 210 patients with DKA tested positive for COVID-19 and they were compared with 4,819 patients with DKA but negative for COVID-19. All patients were admitted to the hospital for DKA and confirmed as having a bicarbonate on admission below 18 mEq/L, a blood glucose over 250 mg/dL, and anion gap over 12 mEq/L. The average age of the cohort was 47 and 53% were men.

All patients were treated with the same computerized continuous insulin infusion algorithm, but those who received insulin treatment for less than 4 hours were excluded.

Upon admission, metabolic parameters — including glucose levels, HbA1c, potassium, sodium, bicarbonate, and anion gap — were similar between patients regardless of COVID-19 status. Also, both groups had similar proportions of hypoglycemia, hypokalemia, and hyperosmolality.

However, those who tested positive for COVID-19 tended to be older and had a higher BMI than negative patients. And those who tested positive and who were also over 65 were more likely to have cardiovascular disease, along with diabetes-related complications like nephropathy, neuropathy, or retinopathy versus younger patients.

COVID-19 patients required more insulin — 5 versus 3.6 units per hour — and also had a prolonged duration of continuous insulin infusions of 34 hours versus 23 hours for COVID-19-negative patients. Positive patients also had, on average, a longer time to DKA resolution, at 5.8 hours versus 4.4 hours, to achieve a blood glucose under 250 mg/dL.

Kristen Monaco is a staff writer, focusing on endocrinology, psychiatry, and dermatology news. Based out of the New York City office, she’s worked at the company for nearly five years.

Pasquel disclosed support from the NIH.

Pasquel and co-authors disclosed relevant relationships with Dexcom, Merck, Boehringer Ingelheim, AstraZeneca, Eli Lilly, Novo Nordisk, and Glytec.

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