Notes from the Community: Diabetes Update

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Maureen A. -

Hi Mel, How common is DKA in Type 2 diabetes? Also any weight to studies that have suggested that high circulation insulin levels in patients with insulin resistance may be contributing to macrovascular disease rather than high sugars. One wonders if giving these insulin resistant patients more insulin to manage their disease may be doing more harm then benifit. Just a thought.

Mel H. -

First DKA in type II is supposed to NOT happen by definition. It does, but not often. Yes, it may well be that insulin given to these patients is BAD. We have having the world expert on DKA and NIDDM come to rounds next month and we will get her on EMRAP soon.

Steve U., M.D. -

Great summary talk on the out of control or new onset diabetic. At our hospital we give IV fluids and Humalog or Novalog SQ until we get the sugar down to what we consider a reasonable range ( usually less than 300). An ongoing debate at our hospital is what do with the diabetic who has ketosis (as measured by an elevated Betahydroxybutyrate ) but no acidosis ( as measured by a normal venous ph and normal HCO3). There is one school of thought that the betahydroxybutyrate is too sensitive of a test (when compared to the previously used serum ketones) and that mild elevations are clinically insignificant. The other school of thought is that all ketosis must be cleared prior to discharge. I don't think there's any literature out their addressing this issue so we're subject to asking the "magic eight ball" (for an online version "should I admit this patient?"
As to Dr M comment that "First DKA in type II is supposed to NOT happen" is theoretically true but as he said in the next sentence " It does, but not often" (Is this Australian doublespeak?). When it does occur look very closely at the underlying cause of of the out of control blood sugar in the type II. It's the same differential as for HHNC. Here's a review article discussing this: Case Study: Diabetic Ketoacidosis in Type 2 Diabetes: “Look Under the Sheets” welch and Zib Clinical Diabetes October 2004 vol. 22 no. 4 198-200

Jose Diaz PA-C -

I work in a remote setting and refer to an ER about 1.5-3 hours away (depending on weather and road conditions). Is it worthwhile treating hyperglycemic ketotic patient with insulin? The only way I have to check fo ketoacidosis is a UA dip for ketones. Many if not all do not have a primary care provider. Or should I just stick to fluids?

PS: we get no guidance or communication from the ER docs on this or any other issue.

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