Diabetic Ketoacidosis With COVID-19 Deadly for Aged and Overweight Diabetes Sufferers


Patients with diabetic ketoacidosis and a COVID-19 diagnosis were increasingly dying than patients with diabetic ketoacidosis without COVID-19. This is shown by an analysis recently published in JAMA Network Open.

Published online March 10 as a research letter, physicians under the direction of Francisco J. Pasquel, MD, MPH, of Emory University School of Medicine, Atlanta, performed an analysis of data from Glytec’s national database. The analysis included 5,029 patients with diabetic ketoacidosis treated at 175 hospitals in 17 states between February 1 and September 1. 15, 2020. Most patients were COVID-19 free (4,819 or 96%), but 210 (4%) patients were positive for COVID-19 and of these 64 (or 30%) died compared to 262 of 4,819 ( 5%) without COVID-19.

Why a COVID-19 diagnosis was more fatal for patients with diabetic ketoacidosis is unknown, but researchers suggest that other factors – such as advanced age or a high BMI – may play a role.

“The cause of the significantly higher mortality in the COVID-19 positive population is unknown. Factors could include obesity and a more severe state of stress (suggested by higher insulin needs). These results are worrying and warrant further investigation, ”the authors wrote.

Diabetic ketoacidosis occurs as a result of high blood sugar levels and a lack of insulin, so treatment usually involves continuous infusions of insulin. The condition can be exacerbated by hyperglycemia, dehydration, and acidosis-inducing disorders in the intermediate metabolism.

In recent years, more people have been hospitalized for diabetic ketoacidosis. However, hospital deaths have decreased in this group of patients. However, this study shows that a COVID-19 diagnosis for diabetic ketoacidosis reversed that trend.

Pasquel et al. analyzed severity markers for diabetic ketoacidosis, insulin requirements, complications and hospital deaths of patients with and without COVID-19.

Patients with COVID-19 were on average older (56 years mean age) compared to the mean age of 47 years for the study as a whole. Patients with COVID-19 also had a higher body mass index (31 (P <0.001) compared to the study mean of 28 (P <0.001). Older patients with COVID-19 (65 years and older) were more likely to have complications due to Cardiovascular disease and diabetes compared with patients who were 45 years of age or younger (cardiovascular diseases: 16) [22%] vs 1 [2%] (P <0.001). Diabetes complications occurred in 10 [14%] Patients with COVID-19 compared to 1 [2%] without (P = 0.02). The metabolic parameters (glucose, hemoglobin A1c, potassium, sodium, bicarbonate and anion gap) were similar in patients with and without COVID-19. COVID-19 patients were more likely to have acute kidney injury (64 out of 210) [30%]) compared to patients without COVID-19 (498 of 4,819 [10%]).

Regardless of the COVID-19 status, mortality has been adjusted for advanced age. In patients 65 years of age and older with COVID-19, the mortality was 45% (33 out of 73 patients) and 13% (110 out of 860 patients) in patients without COVID-19.

Pasquel et al. found that a COVID-19 diagnosis in younger patients (45 years of age and younger) was consistent with a higher mortality rate (19% or 10 out of 54 patients) compared to 2% (41 out of 2,290 patients) in those without COVID-19 .

COVID-19 patients had higher insulin needs and longer periods of continuous insulin infusions to correct their diabetic ketoacidosis status. Hypokalaemia and hyperosmolality were common in both groups. The rates of hypoglycaemia were similar in both groups.

“In this analysis, the mortality observed in patients with COVID-19 was high and increased across ages, with older adults (> 65 years of age) having a mortality of 45%,” the authors wrote.

Limitations identified in this study included the lack of data on the registration diagnosis, race, duration of diabetes, additional disease severity markers, or COVID-19-specific therapy such as corticosteroid use.

“During the COVID-19 pandemic, several changes are occurring in diabetes care to reduce the number of patient interactions. However, it is not known whether fewer interactions can increase mortality by delaying the resolution of diabetic ketoacidosis.

Information: Dr. Pasquel said he received research support from Dexcom and Merck and personal fees from Boehringer Ingelheim, AstraZeneca, Eli Lilly and Co, and Merck outside of the work submitted. Several other authors also reported receiving grants from pharmaceutical companies.


Pasquel FJ, Messler J, Stand R, et al. Features and Mortality Associated with Diabetic Ketoacidosis in US Patients Admitted to Hospital With or Without COVID-19. JAMA Netw Open. 2021; 4 (3): e211091. doi: 10.1001 / jamanetworkopen.2021.1091