Emergency admissions for diabetic ketoacidosis (DKA) rose during the COVID-19 pandemic among people with type 2 diabetes and those without a prior diabetes diagnosis, but at the same time dropped among those with type 1 diabetes, new UK data suggest.
“The prompt recognition of new-onset diabetes and the features of those at risk of DKA in people with type 2 diabetes are key to mitigating the excess DKA admissions observed during the COVID-19 pandemic,” write Shivani Misra, PhD, and colleagues in their article published online September 2 in Lancet Diabetes & Endocrinology.
The data are from the Secondary Uses Service repository, a multiethnic national database of emergency admissions in England. DKA admissions were compared from the “first wave” from March 1 to June 30, 2020, the “post-first wave” from July 1 to October 31, 2020, the “second wave” from November 1, 2020 to February 28, 2021, and the equivalent pre-pandemic periods in 2017-2020.
This is believed to be the largest analysis to date of DKA cases in a complete national dataset.
There was an overall rise in all hospital admissions with DKA during all pandemic “wave” periods compared with pre-pandemic periods. But while there was a significant rise in DKA admissions for people with type 2 diabetes and those with new-onset diabetes, there was a concurrent significant reduction in people with type 1 diabetes presenting with DKA. These trends were similar in both “waves” despite the minimal availability of SARS-CoV-2 testing in the first wave compared with universal availability during the second, note Misra, of National Health Service England’s National Diabetes Audit Programme, London, UK, and coauthors.
Focus on Those at Greatest Risk, Empower Patients to Help Themselves
Study coauthor Partha Kar, MD, told Medscape Medical News that one important lesson to learn is to focus on people with diabetes who are at greatest risk.
“We’ve done diabetes care as one-size-fits-all. But now the advice is, can we focus on people with higher A1c, which ties directly to deprivation and ethnicity, regardless of what country you’re in…We probably need to do much more honed-in looking into people with higher risk factors in readiness for another pandemic,” he said.
Kar noted that the rise in DKA among those without a prior diabetes diagnosis points to the still-burning question of whether SARS-CoV-2 triggers the disease.
The global CoviDIAB registry was set up in 2020 to track this.
On the other hand, Kar said, “I think the type 1 story has been quite a pleasant surprise. You would expect things to overall get worse in pandemic since you wonder about access to care.” But, he noted, several projects have been launched in the UK to help people with type 1 diabetes during the pandemic, including a Twitter account and a website run by a voluntary UK-based multidisciplinary group of diabetes specialists who answer questions. Kar was among the creators.
In addition, a national diabetes helpline was opened for people with diabetes, “so if you’re struggling you can just phone up a line rather than having to wait for your local center. You can just dial the line and have some advice,” Kar said.
Another factor was the huge surge in uptake of the Abbott Libre continuous glucose monitor system in England, “which obviously helped in self-management.”
Kar said the message in all that is, “If you encourage more self-management and peer support in the population, you will get better bang for your buck as a health system rather than concentrating on trying to get more healthcare professionals…Yes, we need access to trained professionals obviously, but I think we have underestimated what patients can do themselves if they have the right tools given to them.”
DKA Trends During COVID-19 Differ by Diabetes Type
The numbers of emergency hospital admissions coded with DKA were 8553 during the first wave, 8729 post-first wave, and 10,235 during the second wave. Those numbers represent increases of 6%, 6%, and 7%, respectively, compared with the equivalent pre-pandemic time periods (all P < .0001).
The 4041 DKA admissions among people with type 1 diabetes during the first wave represented a 19% drop compared with pre-pandemic.
In contrast, DKA admissions among those with previously diagnosed type 2 diabetes increased by 41% during the first wave compared with pre-pandemic and increased among those newly diagnosed with diabetes by 57% (all P < .0001).
During the second wave, DKA admissions were 25% lower for those with type 1 diabetes compared with pre-pandemic, 50% higher for type 2 diabetes, and 61% higher among those with newly diagnosed diabetes (all P < .0001).
During both the first and second waves, the reduction in DKA admissions in people with type 1 diabetes was mainly among those younger than 30 years.
In type 2 diabetes, excess DKA cases in both waves occurred in older people with similar demographic characteristics to those presenting prior to the pandemic.
The trend of higher type 2 diabetes and DKA admissions persisting in the post-first wave into the second wave “might reflect behavioral changes, reduced contact with healthcare providers, a possible direct effect of SARS-CoV-2 on the pancreas, or extension of the yearly rise of DKA in type 2 diabetes, which has been reported previously,” Misra and colleagues write.
Misra has reported receiving a grant in support of an investigator-initiated study from Dexcom. Kar has reported no relevant financial relationships.
Lancet Diabetes Endocrinol. Published online September 2, 2021. Full text
Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.