Unusually high rates of DKA seen in COVID-19

An unusually high number of people presenting with COVID-19 disease in the UK are developing diabetic ketoacidosis, hyperosmolar hyperglycaemic state, or a combination of both, which require high doses of insulin.

Guidance on the management of DKA from the UK’s National Diabetes Inpatient COVID-19 Response Group has included a back-up option of using subcutaneous insulin when IV insulin infusion is not possible.

“The increased demand for pumps to deliver inotropes has led to concerns of possible shortages of infusion pumps and/or 50 ml syringes being available for insulin infusions to manage these hyperglycaemic emergencies,” the Group said in a Letter to Diabetic Medicine.

In response to clinician requests for a subcutaneous insulin regimen, the group has recommended 4-hourly subcutaneous rapid-acting insulin at an initial dose of 0.4 units/kg every four hours then reducing to 0.2 units/kg every four hours once the blood glucose is <14mmol/L.

Treatment should be maintained until ketones are <0.6 mmol/L.

If ketones were not falling as expected, the advice is to increase rapid-acting insulin dose to 0.5 units/kg every 4 hours, contact the diabetes specialist team and consider switching to IV insulin if an infusion pump is available.

The guidance includes recommendations for monitoring the patients, advice to continue or commence basal insulin once targets have been achieved, and two alternative IV fluid replacement regimens.

“The second is a more cautious regimen for COVID-19 positive/suspected patients with consideration of a higher rate of fluid replacement if there is significant hypovolaemia or acute kidney injury,” it said.

“Importantly, clinical judgement, frequent senior review, and regular monitoring of fluid balance and oxygen saturations are advised.”

It said the effect of COVID-19 disease on potassium regulation remains unknown, so potassium replacement should follow standard protocols and be guided by 2-hourly monitoring.

The Group said while most teams will not need to use the subcutaneous insulin strategy, it would be a welcome option in less well-resourced countries.

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