Which Diabetes Patients Are at Risk for a Hyperglycemic Crisis?

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Certain factors may help predict just who is at a higher risk for a hyperglycemic crisis, researchers said.

In a study of over 20,000 adults with type 1 diabetes and another almost 800,000 adults with type 2 diabetes, a slew of sociodemographic and clinical factors were able to identify patients at increased risk for emergency department or hospital visits primarily for the life-threatening diabetic complications of diabetic ketoacidosis or a hyperglycemic hyperosmolar state, reported Rozalina G. McCoy, MD, MS, of the Mayo Clinic in Rochester, Minnesota, and colleagues in JAMA Network Open.

Not surprisingly, the strongest predictor of a patient experiencing a hyperglycemic crisis was a prior history of diabetic ketoacidosis and hyperglycemic hyperosmolar state. For those with type 1 diabetes, these patients saw a near eight-fold increased risk for another hyperglycemic crisis if they had a prior history (incidence risk ratio [IRR] 7.88, 95% CI 6.06-9.99). More alarmingly, though, patients with type 2 diabetes saw a near 18-fold higher risk for a hyperglycemic crisis if they had a prior history (IRR 17.51, 95% CI 15.07-20.34).

A high HbA1c level was the next strongest predictor of a hyperglycemic crisis: both patients with type 1 and type 2 diabetes had a seven-fold increased risk for an incident hyperglycemic crisis if their HbA1c was 10% or higher versus those with a well-controlled HbA1c between 6.5% to 6.9% (IRR 7.81, 95% CI 5.78-10.54 for type 1; IRR 7.06, 95% CI 6.26-7.96 for type 2).

In addition, experiencing severe hypoglycemia was also a strong predictor of a hyperglycemic crisis. For those with type 1 diabetes, a prior severe hypoglycemic episode was tied to a more than two-fold increased risk for hyperglycemic crisis (IRR 2.77, 95% CI 2.15-3.56). This risk was even more pronounced for patients with type 2 diabetes, who saw an over four-fold higher risk for hyperglycemic crisis (IRR 4.18, 95% CI 3.58-4.87).

Several other comorbidities in patients with type 1 and type 2 diabetes had a significant association with the risk for hyperglycemic crisis:

  • Neuropathy: IRR 1.64 (95% CI 1.39-1.93) for type 1; IRR 1.25 (95% CI 1.17-1.34) for type 2
  • Nephropathy: IRR 1.22 (95% CI 1.01-1.48) for type 1; IRR 1.23 (95% CI 1.14-1.33) for type 2
  • Depression: IRR 1.62 (95% CI 1.37-1.92) for type 1; IRR 1.46 (95% CI 1.34-1.59) for type 2

While no other comorbidities assessed were significantly tied to hyperglycemic crisis in patients with type 1 diabetes, several other conditions were predictive for those with type 2 diabetes. These included retinopathy, cerebrovascular disease, peripheral vascular disease, heart failure, dementia, chronic obstructive pulmonary disease, cancer, and cirrhosis.

Still looking just at patients with type 2 diabetes, those on an SGLT-2 inhibitor or who were insulin dependent also saw a higher incidence of hyperglycemic crisis.

Shifting focus to sociodemographic factors, financial stability also played a role in the risk for a hyperglycemic crisis. Specifically, patients with type 1 or type 2 diabetes with a high income — $200,000 a year or higher — had a significantly lower risk for a hyperglycemic crisis than those with a low income of under $40,000 annually (IRR 0.61, 95% CI 0.46-0.81 for type 1; IRR 0.69, 95% CI 0.56-0.86 for type 2). The researchers pointed out that lower income patients are likely more prone to a hyperglycemic crisis because they’re more likely to practice insulin rationing and lack insurance.

On top of this, Black patients with diabetes were more likely to have a hyperglycemic crisis than white patients (IRR 1.33, 95% CI 1.01-1.74 for type 1; IRR 1.18, 95% CI 1.09-1.27 for type 2).

Additionally, midlife and older patients were less likely to experience a hyperglycemic crisis compared with younger patients ages 18 to 44. This extended to both the type 1 and type 2 populations.

This retrospective cohort study analyzed claims and lab results from the OptumLabs Data Warehouse for 20,156 adults with type 1 diabetes (mean age 46.6, 51.2% men, 72.6% white) and 796,382 adults with type 2 diabetes (mean age 65.6, 50.3% women, 54.4% white). Those with type 1 diabetes had an adjusted hyperglycemic crisis rate of 52.69 per 1,000 person-years (95% CI 48.26-57.12), and those with type 2 diabetes had an adjusted rate of 4.04 per 1,000 person-years (95% CI 3.88-4.21).

Taken together, these “findings suggest that multidisciplinary interventions focusing on groups at high risk of hyperglycemic crises are needed to decrease the incidence and impact of these potentially preventable complications of diabetes,” wrote McCoy and colleagues.

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    Kristen Monaco is a staff writer, focusing on endocrinology, psychiatry, and dermatology news. Based out of the New York City office, she’s worked at the company for nearly five years.

Disclosures

The study was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

McCoy reported receiving an AARP Quality Measure Innovation Grant and grants from the NIDDK and the Mayo Clinic. Other co-authors also reported disclosures.

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