Video The Current State of Preventing DKA: Prevalence, Shortcomings, and New Opportunities Play Pause Volume Quality 1080P Fullscreen Captions Transcript Chapters Slides The Current State of Preventing DKA: Prevalence, Shortcomings, and New Opportunities Overview CLICK HERE FOR CME CREDIT Back to Symposium Hello. It's a great pleasure today to present the Current state of Preventing DKA. We'll talk about the prevalence and the shortcomings, of which you'll see there are many, and the new opportunities which we're very hopeful uh will come before too long. These are my disclosures. What is DKA? Let's just start there to get it, uh, to get it clear, so we're all on the same page. DKA you need to have diabetes, ketosis, and acidosis, all three of the D, K, and A. But just notice up on the top there for diabetes. It's really just a history of diabetes. It's no longer glucoses of 3 and 4 and 500. As long as you have a history of diabetes, that's enough to qualify for the D, or if you don't have a history and your glucose is 200 or more. So that's DKA beta hydroxybutyrate over 3 millimoles and uh acidosis by pH or bicarb. Uh, so once we have the definition, How did we get there? And again, I'm not gonna spend a long time on this. You're all fairly familiar, but it's important to know DKA is because you have insulin deficiency. You really have to be deficient in insulin, and then some other event happens that gets the counterregulatory hormones going. You don't have enough insulin, you start to break down fat, you get free fatty acids that get turned into ketone bodies, and you get ketogenesis. And you may very well likely have hyperglycemia, that's DKA. But remember, there's this term now called euglycemic DKA and it's the same pathway, insulin deficiency, ketosis, but now if you're on an SGLT2 inhibitor, You're passing that extra glucose, hyperglycemia out in the urine, so you've got ketosis. And glucoses that look relatively normal. So it's called euglycemic DKA and that's relative euglycemia. It doesn't mean it's perfectly normal, but it's not very elevated glucoses. And then you got to treat it. And again, I'm not gonna go into the details. You need insulin, you need fluids with a little potassium, you need carbohydrates, and don't forget about treating the precipitating causes. Stop the SGLT-2 if you're on it, treat the infections. Talk about alcohol, substance abuse, strokes, trauma. Uh, did someone miss their insulin? So that's the pathway to get there. And you notice I mentioned SGLT-2s several times, and I'm sure you'll hear more about those in the upcoming discussions because they're really important drugs and we need to work this in and be sure we're preventing the ketosis that can be associated with the very positive effects. OK, that's DKA. Is it a major health problem? Yes, it is a major health problem. It's common. It's a leading cause of, uh, of events leading to hospital admissions, 4 to 8%. I'll show you some data in just a minute. Maybe it's 2 to 6% now, but A fair number of people have an annual incidence rate of DKA if you have type 1 diabetes. It's costly 2,000,000 to $30,000 to $40,000 and if you've had one event, you might have another, and the second event is even more expensive. It's dangerous. People don't really realize it's the leading cause of death among children with diabetes and young adults, and it can happen in type 1 and type 2. Yes, much more common in type 2, but look at those numbers. Type 2 has a higher mortality rate. So although the numbers are less, it's really dangerous, uh, for people with type 2 to get ketoacidosis. I love this slide, just talking a little bit more, and maybe you'll hear more about it later, but this is a pediatric uh uh slide, really, but it's A study out of Australia where they're trying to prove that automated insulin delivery is really a good way to deliver insulin, that it, it cuts down admissions and costs, and yes, that's true, but the reason I'm showing it is right over here on the left-hand side. Using automated insulin delivery decreased hypo admissions. Look at that down to 2 over this time period, but there were 10 DKA admissions, 5 times as many. And, and the pumps and the MDI had some hypo emissions, but they had 2 to 3 times more DKA. So, as much as we work to prevent hypo, prevent hypo, we should be putting equal, if not more attention to preventing DKA. I'm showing you just a couple of slides here, Doctor Shear and Doctor Wyam, uh, who you'll hear from later, leaders in this field, have a, have a poster, uh, at the ADA, uh, this year, and just focus on the left. In type 1 diabetes, the incidence of DKA is going up. Well, maybe it's leveled a little, but it's on the rise. Type 2 diabetes, just on the left, it's going up. So, this isn't about to stop. We haven't turned it around despite other advances we've made in diabetes management. It needs attention. And one more abstract. That's available. Doctor Alan Dio, uh, who's really a leader in this space too, and I'll just focus your attention to his, uh, contribution that's at the ADA this year. Look at the right-hand side that I've highlighted in yellow. 1/3. Of hospitalizations for people with type 1 diabetes in the United States were for DKA. One third of all the admissions, that's over $1.24 billion and that was a couple of years ago. I'm sure it's 1.5 to $2 billion in cost now. So, this deserves attention, costly, dangerous. And frequent So what do, so what do, what do people think about it? So this is a really nice study. So you're interviewing uh patients in an endocrine clinic. How familiar are you with DKA? 32%, 13, are only familiar with that term DKA. Can you tell me a little bit about the symptoms of DKA? No. For, for almost half the people. I heard the term maybe. I don't really know exactly what the symptoms would be. Well, do you test for ketones? 60% plus don't test. They don't test even when their sugars are 3 or 400. So, awareness is not really top of mind for patients. But that was a survey. How about some real data? So I was fortunate to be part of an author team that just published this, uh, uh, um, in May, uh, just last month, and You see, in this study, It was people, not in the US but in, in Europe and Asia who were using um a CGM, so they had a state of the art CGM. They could see all their glucoses. They also in this, in the reader that they had to look at the data from the CGM, you could insert a ketone strip. So you could measure ketones. So whenever the glucoses got into a range where they were recommended to test ketones, they have that right available. And this was 89 countries, 10 years of follow-up. So amazing amount of data, 135,000 patients for 10 years. Think of how much data that is of glucose. 92.5% of the people never checked their ketones over those 10 years. Um, and you know they had high glucoses. We know they had high glucoses over 250 quite often, and if they did test the ketone, it was 5 or 8 hours later. And if they did test it, if they did test the ketone, they didn't recheck it, hardly ever. And there were elevated ketones when the glucoses were uh well under 250 where you're, where we're telling people to start checking. So the data says people aren't checking a lot. They tended to check on median here in the red line on the right at 300 is when they thought about checking. Again, it was only a small percentage. Uh, we, we tell people on the yellow line to check when you're over 250. They waited till 300. And most of the, most of the values were normal, but 13% were high if they took the time to check. And then finally, just in that study, just to make the point again, and maybe look at the table on the left because it's even easier to understand than graphs. Sometimes we think graphs are better, but People who did measure their ketones and had a level of 3 millimoles per liter, so that's consistent with the diagnosis of DKA, they waited almost 8 hours of, of, of hyperglycemia. So they had 8 hours over 250 before they checked their ketones. And had 5 hours if they were 1.5 to 2.9, and you'll hear more about these levels of ketosis uh later, I'm sure. But just to say that people aren't that aware of it, even when they have the technology in front of them, they don't seem to do the tests, certainly not as we're recommending. What's the problem with the current testing? Here's what we have available to us. On your left, urine strips, on your right, a good ketone meter. I mean, it's really quite accurate, but you got to poke your finger and have the strip available, know where your meter is. And get the reading. People don't like the urine test. I don't have to tell you why. It's not very convenient, not very pleasant. They, the, the, the blood test seems like, well, that would be a, uh, an obvious thing to do, but you, people aren't carrying meters anymore. They have continuous glucose monitoring. They don't know where their meter is when they need it. It's not with them in the car. It's not at the cabin. Um, so, this technology, although it could detect ketones, uh, we've shown you now in several instances, it just isn't being used, uh, as it should be. Well, maybe we don't need all that. Maybe just doing continuous glucose monitoring will solve this problem. If we know our glucoses, we can prevent ketoacidosis. Yes? No? Let's look at the data. How are you going to find out? If glucoses and ketones go up together, if they go up together. Lockstep, and barrel, then maybe we don't need to measure ketones. So, this is the work from Doctor Jen Shear at Yale, and I thank her for being able to use her slides. She's used them before and, and, and, and, and, and taught us all a lot. This shows ketones on the, on the uh glucose on the top, ketones on the bottom, when you come in and you're on an AID system or you're on a, a pump and, and, and you stop the infusion of insulin. Now, yes, you gotta be watched carefully. You gotta be in a research setting, but you just turn off the insulin, you have type one diabetes, and you wait, and you know the glucoses are gonna go up because no insulin is being delivered, and you wonder if ketones are gonna follow suit. So here's a whole bunch of people and you can't quite tell, can you, by looking if the greens follow the green and the red follows the red. So let me show you just a couple of select cases and see what we learn from these really important and hard to do, uh, take skill of Doctor Shearer and her team. So here's Here's the uh glucoses in black and the ketones, this case in yellow, and we have a couple of cut-off points here. The blue line says you've crossed a ketone mark of over 1 millimole per liter, which says you're definitely elevated because normal is down at 0.6 and you're up above 1. So it's At least you should be concerned. And then the glucose is what I've told you before, we tell people when you're over 250, not just for one reading, but when you have a few readings over 250, You should be concerned because that's when you should start looking. So here's a patient where they did follow pretty closely. The glucoses went up, they crossed 250, the ketones were going up. Most people wouldn't even know that, but they crossed the one about the same point, and they both go up. Glucoses kind of level off though, don't they? And people would think, well, it's just one of those days, but the ketones keep going up to where they're getting really quite high now, 1.5, almost 2. so yes, they go together for a while, but then the ketones keep going up and you wouldn't know it if you're not measuring it unless you got symptomatic. So here's another case. But look at the difference in the rates. Some people's glucoses go up really fast, and the ketones rise right along with them. In this case, look at the ketones. They went up, what is that, 12 hours ahead of the glucose. The glucose levels off, so do the ketones for a minute, but then the ketones really start to go up, and they're getting up close to that 3 range. So don't count on the glucose to tell you the full story, and here's a really important case. Someone's glucose on the top. Again, goes up over that 200, but never really hits 250. This is just a bad day or a day where I can't quite get it under control, but I'm not really worried. I'm just hovering at 180, 190. But the ketones, you're really getting insulin deficient here because the ketones are going up, going up, and they cross the 1, they're up to 1.5. Now it's time to turn off this infusion because we're really having over 1.5 for several hours here. So, This is really important data because it really emphasizes, and I, I summarize it in these three panels. Sometimes the glucose and ketones both go up, OK. Maybe the glucose would give me fair warning if I, if I have some good way to measure it. Sometimes the glucose goes faster and the ketones don't rise as fast, but the third case on the right, and these patients, you really have to be careful. The ketones are going up and the glucose seems pretty good. So you just won't know it by measuring the glucose. So if there's one thing I'm gonna say out of my little short introduction here. Don't count on the glucose to tell you about ketones. And I'll emphasize that, you know, as we're coming towards the, towards a close here, I'll emphasize it once more by this case. So here's a patient and we all see individuals with just high glucoses all the time. Here's their AGP and their glucose profile. They're running, they're running pretty high. This is in millimoles here, but they're running up in the 300 range. And so that means in their daily views, they have a lot of hyperglycemia every afternoon. And they're thinking, well, OK, I live with this. I'm not gonna get ketoacidosis, but which one of those, which one of those high days might they have a urinary tract infection? Might they be exercising strenuously and the ketones go up? Might they have forgotten to take an insulin dose to try to correct this? Any one of those days could be the day that they bump into ketoacidosis and they're not gonna know it unless they're measuring ketones as well. So this person in particular, would really benefit by knowing uh if they're on the verge of ketosis. And probably one of the best studies to summarize this is from France from Doctor Rivlin. I, I love their work because they have a registry and they have all the data on their patients and their uh admissions to the hospital and if they're using continuous monitoring and if they're had DKA or hypoglycemia or got admitted for a coma. So look at this study of people with type 1 on the left, type 2 on the right. And in the blue is before they got CGM. And then the yellow is after they got CGM. So you'd say, congratulations, CGM. It really cut the DKA rate in half. So that's good in half, but even with CGM it's 4 times, 5 times higher. Than the rate of hypoglycemia leading to admissions, the rate of comas, the rate of hypoglycemic admissions. So, CGM, I'm all for it. It's, it really makes a difference. But it doesn't prevent DKA. It's still the highest indicator of people with type 1 and type 2, admissions. So, Who is it that's going to be at risk in particular? Well, here's just a list from this, uh, the expert panel that we put together that was published in The Lancet, Diabetes and Endocrinology, um, uh, early this year online at the end of last year, and we made a table of who we think are the most at risk, uh, for ketoacidosis. And it starts right at the top. I mentioned it a couple of times, I'll say it again. One episode You're likely to have another, as a matter of fact, recurrent DKA is responsible for 20%. Of all DKA admissions. So anything we can do to get those people off of that path and monitoring their ketones would be critical. SGLT-2 inhibitors, I said it before, I'll just say it again since they're such an important therapy to protect the heart and the kidney and, and other positive effects, glucose lowering type 1 and type 2. It's not approved in type 1 yet, but boy, if we could find a way to make it safe to take it in type 1. Pregnant women, um, and insulin pump users. I showed you if they're If their infusion set becomes clogged, they're gonna get glucose and ketone elevations, low carbohydrate diet frail elderly. Kidney disease is a little more questionable. We're not sure. We need more studies to say if they're at higher risk for ketosis. But this was interesting. People who've had a recent history of Heart disease, significant heart disease or neuropathy enough to cause a foot ulcer. are at risk for DKA. So just keep those in mind as you hear about strategies for, for better treatment. So that's my summary. Uh, that's my story of what I think is the current state of DKA and steps that are being taken currently. We need to know it's common, it's costly, it's dangerous, and people really don't understand DKA. OK, that's probably not fair. They don't understand it very well, and people really hardly test their ketones, at least up to the standards of care. And CGM is terrific, but it's not a reliable way to prevent DKA. And it's highest in people who've had an event. Uh, you see it in type 1 and in type 2 diabetes, SGLT2s, very low carb diets, medically underserved. So that's the current state of where we are. I hope that helps, and I can tell you I'm really looking forward to what my colleagues have to say about new innovative strategies. That we can really work on prevention going forward. So thank you very much for your attention. Published June 3, 2026 Created by Related Presenters Richard Bergenstal, MD Executive DirectorPark Nicollet International Diabetes CenterAdjunct Professor, Department of MedicineUniversity of MinnesotaSt. Louis Park, MN
