Type 1 diabetes : Diabetic Ketoacidosis (DKA) – an enemy always lurking

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Schematic of the pathogenesis of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS). Relative or absolute insulin deficiency stimulates hepatic glucose production, which results in hyperglycemia, osmotic diuresis and dehydration. In severe insulin deficiency, the liver will augment ketone body production, culminating in hyperketonemia and, eventually, acidosis. βOHB = β-hydroxybutyric acid; AcAc = acetoacetic acid. Photo: Chesley Sheppard

What is Diabetic ketoacidosis. DKA?

Diabetic ketoacidosis, also referred to as simply ketoacidosis or DKA, is a serious and even life-threatening complication of type 1 diabetes. DKA is rare in people with type 2 diabetes.

DKA is caused when insulin levels are low and not enough glucose can get into the body’s cells.

It can happen when your blood sugar is too high for too long.

It could be life-threatening, but it usually takes many hours to become that serious.

You can treat it and prevent it, too.

Without glucose for energy, the body starts to burn fat for energy.

Ketones are products that are created when the body burns fat.

The buildup of ketones causes the blood to become more acidic.

The high levels of blood glucose in DKA cause the kidneys to excrete glucose and water, leading to dehydration and imbalances in body electrolyte levels.

Diabetic ketoacidosis most commonly develops either due to an interruption in insulin treatment or a severe illness, including the flu.

What Causes DKA?

It usually happens because your body doesn’t have enough insulin.

Your cells can’t use the sugar in your blood for energy, so they use fat for fuel instead.

Burning fat makes acids called ketones and, if the process goes on for a while, they could build up in your blood.

That excess can change the chemical balance of your blood and throw off your entire system.

People with type 1 diabetes are at risk for ketoacidosis, since their bodies don’t make any insulin.

Your ketones can also go up when you miss a meal, you’re sick or stressed, or you have an insulin reaction.

DKA can happen to people with type 2 diabetes, but it’s rare.

If you have type 2, especially when you’re older, you’re more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). It can lead to severe dehydration.

Warning Signs

Test your ketones when your blood sugar is over 240 mg/dL or you have symptoms of high blood sugar, such as dry mouth, feeling really thirsty, or peeing a lot.

You can check your levels with a urine test strip.

Some glucose meters measure ketones, too.

Try to bring your blood sugar down, and check your ketones again in 30 minutes.

Call your doctor or go to the emergency room right away if that doesn’t work, if you have any of the symptoms below and your ketones aren’t normal, or if you have more than one symptom.

Early signs and symptoms of DKA include:

  • Thirst, which arises due to dehydration
  • Excessive urination, which occurs because the kidneys try to rid the body of excess glucose, and water is excreted along with the glucose
  • High blood glucose (sugar) levels
  • The presence of ketones in the urine

Other signs and symptoms of ketoacidosis occur as the condition progresses:

  • Fatigue, which can be severe
  • Nausea and/or vomiting
  • Abdominal pain
  • Flushing of the skin
  • Dry skin
  • Fruity odor to the breath, caused by ketones
  • Difficulty breathing
  • Mental status changes, including confusion or problems with concentration

Signs and symptoms of DKA associated with possible intercurrent infection are as follows:

  • Fever
  • Coughing
  • Chills
  • Chest pain
  • Dyspnea
  • Arthralgia

See Clinical Presentation for more detail.

Diagnosis

On examination, general findings of DKA may include the following:

  • Ill appearance
  • Dry skin
  • Labored respiration
  • Dry mucous membranes
  • Decreased skin turgor
  • Decreased reflexes
  • Characteristic acetone (ketotic) breath odor
  • Tachycardia
  • Hypotension
  • Tachypnea
  • Hypothermia

In addition, evaluate patients for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection is mandatory in all cases.

Testing

Initial and repeat laboratory studies for patients with DKA include the following:

  • Serum glucose levels

  • Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus)

  • Bicarbonate levels

  • Amylase and lipase levels

  • Urine dipstick

  • Ketone levels

  • Serum or capillary beta-hydroxybutyrate levels

  • ABG measurements

  • CBC count

  • BUN and creatinine levels

  • Urine and blood cultures if intercurrent infection is suspected

  • ECG (or telemetry in patients with comorbidities)

Note that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels.

Imaging tests

Radiologic studies that may be helpful in patients with DKA include the following:

  • Chest radiography: To rule out pulmonary infection such as pneumonia

  • Head CT scanning: To detect early cerebral edema; use low threshold in children with DKA and altered mental status

  • Head MRI: To detect early cerebral edema (order only if altered consciousness is present [1] )

Do not delay administration of hypertonic saline or mannitol in those pediatric cases where cerebral edema is suspected, as many changes may be seen late on head imaging.

When to see a doctor

If you feel ill or stressed or you’ve had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit.

Contact your doctor immediately if:

  • You’re vomiting and unable to tolerate food or liquid
  • Your blood sugar level is higher than your target range and doesn’t respond to home treatment
  • Your urine ketone level is moderate or high

Seek emergency care if:

  • Your blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L)
  • You have ketones in your urine and can’t reach your doctor for advice
  • You have multiple signs and symptoms of diabetic ketoacidosis — excessive thirst, frequent urination, nausea and vomiting, abdominal pain, shortness of breath, fruity-scented breath, confusion

Remember, untreated diabetic ketoacidosis can be fatal.

Diabetic ketoacidosis is usually triggered by:

  • An illness. An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones counter the effect of insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.
  • A problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering diabetic ketoacidosis.

Other possible triggers of diabetic ketoacidosis include:

  • Physical or emotional trauma
  • Heart attack
  • Alcohol or drug abuse, particularly cocaine
  • Certain medications, such as corticosteroids and some diuretics

Risk factors

The risk of diabetic ketoacidosis is highest if you:

  • Have type 1 diabetes
  • Frequently miss insulin doses

Uncommonly, diabetic ketoacidosis can occur if you have type 2 diabetes. In some cases, diabetic ketoacidosis may be the first sign that a person has diabetes.

Complications

Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride — and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related to this lifesaving treatment.

Possible complications of the treatments

Treatment complications include:

  • Low blood sugar (hypoglycemia). Insulin allows sugar to enter your cells, causing your blood sugar level to drop. If your blood sugar level drops too quickly, you can develop low blood sugar.
  • Low potassium (hypokalemia). The fluids and insulin used to treat diabetic ketoacidosis can cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.
  • Swelling in the brain (cerebral edema). Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

Left untreated, the risks are much greater. Diabetic ketoacidosis can lead to loss of consciousness and, eventually, it can be fatal.

Prevention

There’s much you can do to prevent diabetic ketoacidosis and other diabetes complications.

  • Commit to managing your diabetes. Make healthy eating and physical activity part of your daily routine. Take oral diabetes medications or insulin as directed.
  • Monitor your blood sugar level. You might need to check and record your blood sugar level at least three to four times a day — more often if you’re ill or under stress. Careful monitoring is the only way to make sure your blood sugar level remains within your target range.
  • Adjust your insulin dosage as needed. Talk to your doctor or diabetes educator about how to adjust your insulin dosage in relation to your blood sugar level, what you eat, how active you are, whether you’re ill and other factors. If your blood sugar level begins to rise, follow your diabetes treatment plan to return your blood sugar level to your target range.
  • Check your ketone level. When you’re ill or under stress, test your urine for excess ketones with an over-the-counter urine ketones test kit. If your ketone level is moderate or high, contact your doctor right away or seek emergency care. If you have low levels of ketones, you may need to take more insulin.
  • Be prepared to act quickly. If you suspect that you have diabetic ketoacidosis — your blood sugar level is high, and you have excess ketones in your urine — seek emergency care.

Diabetes complications are scary.

But don’t let fear keep you from taking good care of yourself. Follow your diabetes treatment plan carefully, and ask your diabetes treatment team for help when you need it.

Background

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes. DKA mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes (most likely latent autoimmune diabetes of adults [LADA] or Flatbush diabetes).

DKA is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism.

The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes. (See Etiology.)

DKA is defined clinically as an acute state of severe uncontrolled diabetes associated with ketoacidosis that requires emergency treatment with insulin and intravenous fluids. (See Treatment and Management and Medications.)

Biochemically, DKA is defined as an increase in the serum concentration of ketones greater than 5 mEq/L, a blood glucose level greater than 250 mg/dL (although it is usually much higher), and a blood (usually arterial) pH less than 7.3.
Ketonemia and ketonuria are characteristic, as is a serum bicarbonate level of 18 mEq/L or less (less than 5 mEq/L is indicative of severe DKA).
These biochemical changes are frequently associated with increased anion gap, increased serum osmolarity and increased serum uric acid. (See Clinical Presentation.)

Herrington et al collected simultaneous arterial and venous samples from 206 critically ill patients and analyzed in duplicate.

They calculated coefficients of variation and 95% limits of agreement for arterial and venous samples and constructed statistical plots to assess the degree of agreement between samples.

They found that coefficients of variation for arterial and venous samples were similar for pH, serum bicarbonate, and potassium, indicating that both are sufficiently reliable for the management of critically ill patients, particularly those with DKA.

Mental status changes can be seen with mild-to-moderate DKA; more severe deterioration in mental status is typical with moderate-to-severe DKA.

Pathophysiology

Diabetic ketoacidosis (DKA) is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. DKA usually occurs as a consequence of absolute or relative insulin deficiency that is accompanied by an increase in counter-regulatory hormones (ie, glucagon, cortisol, growth hormone, epinephrine).

This type of hormonal imbalance enhances hepatic gluconeogenesis, glycogenolysis, and lipolysis.

Hepatic gluconeogenesis, glycogenolysis secondary to insulin deficiency, and counter-regulatory hormone excess result in severe hyperglycemia, while lipolysis increases serum free fatty acids.

Hepatic metabolism of free fatty acids as an alternative energy source (ie, ketogenesis) results in accumulation of acidic intermediate and end metabolites (ie, ketones, ketoacids).

Ketone bodies have generally included acetone, beta-hydroxybutyrate, and acetoacetate.

It should be noted, however, that only acetone is a true ketone, while acetoacetic acid is true ketoacid and beta-hydroxybutyrate is a hydroxy acid.

Meanwhile, increased proteolysis and decreased protein synthesis as result of insulin deficiency add more gluconeogenic substrates to the gluconeogenesis process.

In addition, the decreased glucose uptake by peripheral tissues due to insulin deficiency and increased counter regulatory hormones increases hyperglycemia.

Ketone bodies are produced from acetyl coenzyme A mainly in the mitochondria within hepatocytes when carbohydrate utilization is impaired because of relative or absolute insulin deficiency, such that energy must be obtained from fatty acid metabolism.

High levels of acetyl coenzyme A present in the cell inhibit the pyruvate dehydrogenase complex, but pyruvate carboxylase is activated.

Thus, the oxaloacetate generated enters gluconeogenesis rather than the citric acid cycle, as the latter is also inhibited by the elevated level of nicotinamide adenine dinucleotide (NADH) resulting from excessive beta-oxidation of fatty acids, another consequence of insulin resistance/insulin deficiency.

The excess acetyl coenzyme A is therefore rerouted to ketogenesis.

Progressive rise of blood concentration of these acidic organic substances initially leads to a state of ketonemia, although extracellular and intracellular body buffers can limit ketonemia in its early stages, as reflected by a normal arterial pH associated with a base deficit and a mild anion gap.

When the accumulated ketones exceed the body’s capacity to extract them, they overflow into urine (ie, ketonuria).

If the situation is not treated promptly, a greater accumulation of organic acids leads to frank clinical metabolic acidosis (ie, ketoacidosis), with a significant drop in pH and bicarbonate  serum levels.

Respiratory compensation for this acidotic condition results in Kussmaul respirations, ie, rapid, shallow breathing (sigh breathing) that, as the acidosis grows more severe, becomes slower, deeper, and labored (air hunger).

Ketones/ketoacids/hydroxy acids, in particular, beta-hydroxybutyrate, induce nausea and vomiting that consequently aggravate fluid and electrolyte loss already existing in DKA.

Moreover, acetone produces the fruity breath odor that is characteristic of ketotic patients.

Glucosuria leads to osmotic diuresis, dehydration and hyperosmolarity.

Severe dehydration, if not properly compensated, may lead to impaired renal function.

Hyperglycemia, osmotic diuresis, serum hyperosmolarity, and metabolic acidosis result in severe electrolyte disturbances.

The most characteristic disturbance is total body potassium loss.

This loss is not mirrored in serum potassium levels, which may be low, within the reference range, or even high.

Potassium loss is caused by a shift of potassium from the intracellular to the extracellular space in an exchange with hydrogen ions that accumulate extracellularly in acidosis.

Much of the shifted extracellular potassium is lost in urine because of osmotic diuresis.

Patients with initial hypokalemia are considered to have severe and serious total body potassium depletion.

High serum osmolarity also drives water from intracellular to extracellular space, causing dilutional hyponatremia.

Sodium also is lost in the urine during the osmotic diuresis.

Typical overall electrolyte loss includes 200-500 mEq/L of potassium, 300-700 mEq/L of sodium, and 350-500 mEq/L of chloride.

The combined effects of serum hyperosmolarity, dehydration, and acidosis result in increased osmolarity in brain cells that clinically manifests as an alteration in the level of consciousness.

Many of the underlying pathophysiologic disturbances in DKA are directly measurable by the clinician and need to be monitored throughout the course of treatment.

Close attention to clinical laboratory data allows for tracking of the underlying acidosis and hyperglycemia, as well as prevention of common potentially lethal complications such as hypoglycemia, hyponatremia, and hypokalemia.

Hyperglycemia

The absence of insulin, the primary anabolic hormone, means that tissues such as muscle, fat, and liver do not uptake glucose.

Counterregulatory hormones, such as glucagon, growth hormone, and catecholamines, enhance triglyceride breakdown into free fatty acids and gluconeogenesis, which is the main cause for the elevation in serum glucose level in DKA.

Beta-oxidation of these free fatty acids leads to increased formation of ketone bodies.

Overall, metabolism in DKA shifts from the normal fed state characterized by carbohydrate metabolism to a starvation state characterized by fat metabolism.

Secondary consequences of the primary metabolic derangements in DKA include an ensuing metabolic acidosis as the ketone bodies produced by beta-oxidation of free fatty acids deplete extracellular and cellular acid buffers.

The hyperglycemia-induced osmotic diuresis depletes sodium, potassium, phosphates, and water.

Hyperglycemia usually exceeds the renal threshold of glucose absorption and results in significant glucosuria. Consequently, water loss in the urine is increased due to osmotic diuresis induced by glucosuria.

This incidence of increased water loss results in severe dehydration, thirst, tissue hypoperfusion, and, possibly, lactic acidosis, or renal impairment.

Dehydration and electrolyte loss

Typical free water loss in DKA is approximately 6 liters or nearly 100 mL/kg of body weight.

The initial half of this amount is derived from intracellular fluid and precedes signs of dehydration, while the other half is from extracellular fluid and is responsible for signs of dehydration.

Patients often are profoundly dehydrated and have a significantly depleted potassium level (as high as 5 mEq/kg body weight).

A normal or even elevated serum potassium concentration may be seen due to the extracellular shift of potassium in acidotic conditions, and this very poorly reflects the patient’s total potassium stores.

The serum potassium concentration can drop precipitously once insulin treatment is started, so great care must be taken to repeatedly monitor serum potassium levels.

Urinary loss of ketoanions with brisk diuresis and intact renal function also may lead to a component of hyperchloremic metabolic acidosis.

Etiology

The most common scenarios for diabetic ketoacidosis (DKA) are underlying or concomitant infection (40%), missed or disrupted insulin treatments (25%), and newly diagnosed, previously unknown diabetes (15%). Other associated causes make up roughly 20% in the various scenarios.

Causes of DKA in type 1 diabetes mellitus include the following: 

  • In 25% of patients, DKA is present at diagnosis of type 1 diabetes due to acute insulin deficiency (occurs in 25% of patients)

  • Poor compliance with insulin through the omission of insulin injections, due to lack of patient/guardian education or as a result of psychological stress, particularly in adolescents

  • Missed, omitted or forgotten insulin doses due to illness, vomiting or excess alcohol intake

  • Bacterial infection and intercurrent illness (eg, urinary tract infection [UTI])

  • Klebsiella pneumoniae (the leading cause of bacterial infections precipitating DKA)

  • Medical, surgical, or emotional stress

  • Brittle diabetes

  • Idiopathic (no identifiable cause)

  • Insulin infusion catheter blockage

  • Mechanical failure of the insulin infusion pump

Causes of DKA in type 2 diabetes mellitus include the following: [6]

  • Intercurrent illness (eg, myocardial infarction, pneumonia, prostatitis, UTI)

  • Medication (eg, corticosteroids, pentamidine, clozapine)

DKA has also been reported in people with type 2 diabetes treated with sodium-glucose cotransporter-2 (SGLT2) inhibitors. [7]

DKA also occurs in pregnant women, either with preexisting diabetes or with diabetes diagnosed during pregnancy. Physiologic changes unique to pregnancy provide a background for the development of DKA. DKA in pregnancy is a medical emergency, as mother and fetus are at risk for morbidity and mortality.

Epidemiology

Despite advancements in self-care of patients with diabetes, DKA accounts for 14% of all hospital admissions of patients with diabetes and 16% of all diabetes-related fatalities. Almost 50% of diabetes-related admissions in young persons are related to DKA. DKA frequently is observed during the diagnosis of type 1 diabetes and often indicates this diagnosis. While the exact incidence is not known, it is estimated to be 1 out of 2000.

DKA occurs primarily in patients with type 1 diabetes. The incidence is roughly 2 episodes per 100 patient years of diabetes, with about 3% of patients with type 1 diabetes initially presenting with DKA. It can occur in patients with type 2 diabetesas well; this is less common, however.

A study by Zhong et al found that in England, for adults with type 1 or type 2 diabetes, there was a growing incidence of hospitalization for DKA between 1998 and 2013. More specifically, the investigators reported that the incidence for patients with type 1 diabetes rose between 1998 and 2007 and then remained at the same level until 2013, while the incidence associated with type 2 diabetes expanded annually by 4.24% between 1998 and 2013. [73]

The incidence of diabetic ketoacidosis in developing countries is not known, but it may be higher than in industrialized nations. [8]

The incidence of DKA is higher in whites because of the higher incidence of type 1 diabetes in this racial group. The incidence of DKA is slightly greater in females than in males for reasons that are unclear. Recurrent DKA frequently is seen in young women with type 1 diabetes and is caused mostly by the omission of insulin treatment.

Among persons with type 1 diabetes, DKA is much more common in young children and adolescents than it is in adults. DKA tends to occur in individuals younger than 19 years, but it may occur in patients with diabetes at any age.

Although multiple factors (eg, ethnic minority, lack of health insurance, lower body mass index, preceding infection, delayed treatment) affect the risk of developing DKA among children and young adults, intervention is possible between symptom onset and development of DKA. [9]

Prognosis

The overall mortality rate for DKA is 0.2-2%, with persons at the highest end of the range residing in developing countries. The presence of deep coma at the time of diagnosis, hypothermia, and oliguria are signs of poor prognosis.

The prognosis of properly treated patients with diabetic ketoacidosis is excellent, especially in younger patients if intercurrent infections are absent. The worst prognosis usually is observed in older patients with severe intercurrent illnesses (eg, myocardial infarction, sepsis, or pneumonia), especially when these patients are treated outside an intensive care unit.

A study by Lee et al reported that in adult patients with DKA, a longer time to resolution was associated with lower pH levels and higher serum potassium concentrations at hospital admission (with both factors being independent predictors). [74]

When DKA is treated properly, it rarely produces residual effects. Before the discovery of insulin in 1922, the mortality rate was 100%. Over the last 3 decades, mortality rates from DKA have markedly decreased in developed countries, from 7.96% to 0.67%. [10]

A fetal mortality rate as high as 30% is associated with DKA. The rate is as high as 60% in diabetic ketoacidosis with coma. Fetal death typically occurs in women with overt diabetes, but it may occur with gestational diabetes. In children younger than 10 years, diabetic ketoacidosis causes 70% of diabetes-related fatalities.

The best results are observed in patients treated in intensive care units during the first 1-2 days of hospitalization, although some hospitals are successful in treating mild cases of DKA in the emergency room (ie, Emergency Valuable Approach and Diabetes Education [EVADE] protocol). A high mortality rate among nonhospitalized patients illustrates the necessity of early diagnosis and implementation of effective prevention programs.

Cerebral edema remains the most common cause of mortality, particularly in young children and adolescents. [1Cerebral edema frequently results from rapid intracellular fluid shifts. Other causes of mortality include severe hypokalemia, adult respiratory distress syndrome, and comorbid states (eg, pneumonia, acute myocardial infarction).

A heightened understanding of the pathophysiology of DKA along with proper monitoring and correction of electrolytes has resulted in a significant reduction in the overall mortality rate from this life-threatening condition in most developed countries.

A study by Hursh et al indicated that acute kidney injury (AKI) is a frequent development in children hospitalized for DKA. Of 165 hospitalized pediatric DKA patients in the study, AKI developed in 106 (64%). Using an adjusted multinomial logistic regression model, the investigators found a 5-fold increase in the chance of severe AKI (stage 2 or 3) when a patient’s serum bicarbonate level was below 10 mEq/L, while the likelihood of severe AKI rose 22% with each increase in the initial heart rate of five beats/min. The odds of mild AKI (stage 1) developing rose by three fold with an initial corrected sodium level of 145 mEq/L or more. [11]

A study by Chen et al indicated that among persons with type 2 diabetes, those with DKA have a 1.55 times greater risk of stroke than do those without DKA. The stroke risk was particularly high in DKA patients with hypertension and hyperlipidemia and in the first six months after the diagnosis of DKA. [12]

Patient Education

The introduction of diabetes educational programs in most diabetes clinics has contributed to a reduction in the occurrence of diabetic ketoacidosis (DKA) in patients with known diabetes. Such programs teach patients how to avoid DKA by self-testing for urinary ketones when their blood glucose is high or when they have unexplained nausea or vomiting and adjusting their insulin regimens on sick days.

It is essential to educate patients in the prevention of diabetic ketoacidosis (DKA) so that a recurrent episode can be avoided. Central to patient education programs for adults with diabetes is instruction on the self-management process and on how to handle the stress of intercurrent illness. [1314]

The patient education program needs to ensure that patients understand the importance of close and careful monitoring of blood glucose levels, particularly during infection, trauma, and other periods of stress.

*-*- UPDATE 2018*-*-

Add-on empagliflozin improves glycemic control in type 1 diabetes

The addition of empagliflozin to insulin therapy reduces glycated hemoglobin (HbA1c) levels in patients with type 1 diabetes, indicate findings from the phase III EASE-2 and 3 trials.

Moreover, the results suggest that the use of a 2.5 mg dose of the sodium-glucose cotransporter (SGLT)2 inhibitor – a lower dose than those currently approved for type 2 diabetes – may have a favorable benefit–risk profile in patients with type 1 disease, said the EASE (Empagliflozin as Adjunctive to Insulin Therapy) investigators at the 54th EASD Annual Meeting in Berlin, Germany.

Presenting the efficacy results from EASE-2, Julio Rosenstock (Dallas Diabetes Research Center at Medical City, Texas, USA) reported that the 243 patients who were randomly assigned to receive once daily oral empagliflozin 10 mg and the 241 patients who were allocated to the 25 mg dose experienced significantly greater reductions in average HbA1c levels from baseline to week 26 than the 239 patients in the placebo group.

Specifically, adjusted mean HbA1c levels decreased by 0.54% in the 10 mg group and by 0.53% in the 25 mg group relative to placebo, indicating that “empagliflozin clearly is effective at reducing HbA1c in people with type 1 diabetes,” said Rosenstock.

And in the EASE-3 trial, which included the 2.5 mg daily dose of empagliflozin in addition to those tested in EASE-2, all three doses resulted in a significant improvement in glycemic control compared with placebo, but the magnitude of the reduction in average HbA1c levels relative to placebo (n=238) was smaller for the 237 patients receiving empagliflozin 2.5 mg compared with those given the 10 mg (n=244) and 25 mg (n=242) doses, at 0.28%, 0.45%, and 0.52%, respectively.

Rosenstock described a similar pattern of results for decrease in bodyweight, insulin dose, and systolic blood pressure, with the 2.5 mg dose giving rise to significant reductions relative to placebo, but with the two higher doses having a greater benefit.

Bruce Perkins (University of Toronto, Ontario, Canada), who presented the safety results, said that “so far, the general safety [of empagliflozin in type 1 diabetes] is essentially similar to the known safety profile in type 2 diabetes.”

He reported that the incidence of adverse events (AEs) and serious AEs was “balanced between treatment groups” overall, with corresponding rates of 80.5–89.8% and 5.4–13.0%. There was a greater incidence of genital tract infections among patients treated with empagliflozin versus placebo, but rates were lower among those treated with the 2.5 mg dose compared with the higher doses (5.4 vs 12.8–14.3%).

Rates of investigator-reported hypoglycemia and severe hypoglycemia were not significantly different across the treatment groups, but the incidence of patient-reported hypoglycemia was significantly lower among participants given empagliflozin 10 mg and 25 mg compared with placebo.

Perkins said that, in accordance with previously reported trials of other SGLT2 inhibitors, patients given the two higher doses of empagliflozin had an elevated risk for diabetic ketoacidosis (DKA) compared with placebo-treated patients, with adjudicated rates of 3.3–4.3% versus 1.2%. He stressed, however, that the confirmed rate of DKA was “low and similar to placebo” among participants given the 2.5 mg dose, at 0.8%, suggesting that “lower SGLT2 doses conceivably may help to minimize this risk in [type 1 diabetes].”

Commenting on these findings, Thomas Pieber (Medical University of Graz, Austria) recommended that full dose-response studies, including an additional empagliflozin dose of 5 mg, are “urgently needed” before empagliflozin can be recommended as an adjunct to insulin in type 1 diabetes, and called for biomarker investigations to identify patients at high risk for DKA.

The EASE results have also been published in Diabetes Care.

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