HOW CAN WE PREVENT RECURRENT-DKA?

Transcription

1 pinterest HOW CAN WE PREVENT RECURRENT-DKA? Birgit Rami-Merhar

2 DKA is not only a problem at the onset of T1D T1D-children at risk for recurrent DKA: 1-10%/patient/year (ISPAD 2014) mortality rate from DKA: % Cerebral edema accounts for 60 90% of all DKA deaths Complications: children without overt neurological symptoms during DKA treatment may have subtle evidence of brain injury, particularly memory deficits, after recovery from DKA Other complications (e.g. thrombosis, rhabdomyolysis, acute renal failure, )

3 Morbidity and Mortality of Diabetic Ketoacidosis With and Without Insulin Pump Care. Realsen, Chase et al. DIABETES TECHNOLOGY & THERAPEUTICS 2012 Review-Article 3 European population-based studies > T1D patients Onset death excluded DKA =most common cause of death in young T1D-patients DKA related death: 15-19% of all deaths Mortality due to DKA 3 times greater than for SH.

4 What has changed over the years?

5 Changes in Pediatric Diabetes Therapy over 20 yrs Bohn et al, DPV (Germany and Austria, n= 63,967 T1D <18yrs, Plos One 2016

6 Bohn et al, DPV (Germany and Austria, n= 63,967 T1D <18yrs, Plos One 2016

7 Improved Metabolic Control Rosenbauer et al, Diabetes Care 35:80 86, 2012

8 Who is at risk for recurrent DKA??

9 Hospital admission for DKA or SH in young patients with type 1 diabetes (GER/AUT). Karges et al., European Journal of Endocrinology (2015)

10 Maahs et al Diabetes Care 2015 Rates of Diabetic Ketoacidosis: International Comparison With 49,859 Pediatric Patients With Type 1 Diabetes From England, Wales, the U.S., Austria, and Germany Differences between the registries (HbA1c, pump-use and DKA-rate) Overall findings:

11 Girls Female Male Age (yrs) Metabolic control as reflected by HbA1c in children, adolescents and young adults with type-1 diabetes mellitus: combined longitudinal analysis including 27,035 patients from 207 centers in Germany and Austria during the last decade. Eur J Pediatr 167(4): Gerstl EM, et al. (2008)

12 Metabolic changes during puberty (adapted from Monatsschrift Kinderheilkunde 2015) insulinresistance insulindosage weight gain poor compliance omission of insulin eating disorder poor metabolic control DKA

13 Predictors of Acute Complications in Children With Type 1 Diabetes. Rewers et al (US) JAMA N=1243 <19 yrs T1D Denver, Colorado, Were followed up prospectively for from (5yrs) DKA: 8/100 Pat yrs

14 Psychiatric disorders in T1D youth Eating disorders depression anxiety Other psychiatric disorders (e.g.bipolar) Often underdiagnosed and undertreated

15 Identify those at risk for recurrent DKA (1-10%/patient/year), ISPAD guidelines 2014 Children who omit insulin Children with poor metabolic control or previous episodes of DKA Peripubertal and adolescent girls Gastroenteritis with persistent vomiting and inability to maintain hydration Children with psychiatric disorders, including those with eating disorders Children with difficult or unstable family circumstances (e.g. parental abuse) Children with limited access to medical services Insulin pump therapy still verifiable??

16 CSII and risk for DKA CSII may increase the risk for DKA (no long-acting insulin used) DKA-prevalence in CSII-Pat: 2,7-9/100 Pat-yrs Most frequent cause of DKA in CSII Omission of bolus (48,6%) Gastroenteritis (14,1%) Technical pump problems (12,7%) DKA-frequency not different between CSII and MDI DKA in young children with CSII: very rare Highest risk in adolescents (15-25 yrs) with CSII (T1DX) Fritsch M et al. Pediatric Diabetes 2011 Weissberg-Benchel J et al, Diabetes Care 2003 Hanas R et al Pediatric Diabetes 2009 Berghäuser MA et al. Pediatric Diabetes 2008 Philip M et al., Diabetes Care 2007 Karges et al., European Journal of Endocrinology 2015

17 Emergency plan for CSII and high BG If you are using Apidra/Humalog/Novo Rapid in your pump: Check blood-ketons if: BG is >250 mg/dl If you feel unwell/ vomiting/stomach ache Infection with fever

18 Any intervention programms evaluated? Diabet. Med. 32, (2015) Aim: to reduce hospital readmissions due to DKA, hyperglycemia or severe hypoglycemia N= 58 diabetes patients (50 T1D, mean age 35 yrs) readmitted consecutive patients 32/58 had a pre-existing mental health issue 14/58 had a complex social situation

19 Strategies implemented: Simmons et al., Diabet. Med. 32, (2015) Case manager gets in in contact with patient Establishes a relationship Home visit (60%) Patient education (94%) Mental health management Technology (34%,CSII, CGMS, BGM, Pens) Social intervention (32%) Support (78%) outside office hours (24/7-hotline, home visits) Clinical management (20%): sick days, co-morbidities

20 Monthly admission rates Simmons et al., Diabet. Med. 32, (2015)

21 Conclusion-recurrent DKA Recurrent DKA is an ongoing problem We need to identify the patients at risk Most frequent reason: omission of insulin Infection only is rarely the case CSII-therapy has no increased risk for DKA anymore Teach ketone measurement (preferably blood-ketones) 24h hotline Apps with sickday-management-advise could help

22 Conclusion-recurrent DKA Look for psychosocial reasons (e.g. eating disorder, depression, problems at home, insurance?) Engage a multidisciplinary team (including social workers and psychologists) Intensify diabetes education for those at risk and their caregivers (incl. school), have someone to observe insulin dosing Teach GP s and medical students to diagnose DKA Consider using CSII in recurrent DKA-patients It takes a lot of effort and support to reduce recurrent DKA

23 Still a lot to do.

24 Thank you for the attention!