Recurrent Diabetic Ketoacidosis: Prevention and Management by Community Pharmacists
It doesn’t take a health professional to understand the serious threat posed by diabetic ketoacidosis. The problem is that people—including many in the health field—assume it only occurs in those who have type 1 diabetes. Patients with type 2 diabetes also develop ketoacidosis, probably more often than you realize, and can also end up with recurrent episodes. And every time a patient has another episode, their risk of death increases. Community pharmacists can help prevent recurrent diabetic ketoacidosis through consistent medication management and patient outreach.
What Pharmacists Should Know about Diabetic Ketoacidosis
A retrospective review of adults with diabetic ketoacidosis (DKA) found that 47 percent had type 1 diabetes, 26 percent had type 2 diabetes and the rest were newly diagnosed. 1 Another population-based study reported similar results, saying that type 2 diabetes accounted for up to one-third of all cases of DKA.2 In youth who are newly diagnosed with type 2 diabetes, the prevalence of DKA is estimated to be 6 to 12 percent. 3
The top causes of diabetic ketoacidosis in patients with type 1 diabetes include:4
- Underlying infection – causes 40 percent of DKA cases
- Non-adherence to therapy – triggers 25 percent of cases
- New onset diabetes – responsible for 15 percent of cases
- Stress – medical, surgical or emotional
- Mechanical failure of the insulin infusion pump
In patients diagnosed with type 2 diabetes, DKA is caused by:
- Severe illness – including pneumonia, urinary tract infection, prostatitis, and myocardial infarction
- Medications – SGLT2 inhibitors, corticosteroids, pentamidine, clozapine, and some diuretics
- Non-adherence to medication therapy
When DKA occurs in patients with type 2 diabetes, they’re typically older, the episode is more severe, and it has a higher mortality rate compared to DKA in patients with type 1 diabetes. An emerging group of patients at risk for DKA also have a different type of diabetes—ketosis-prone diabetes—which is sometimes known as atypical diabetes, reversible diabetes , or Flatbush diabetes.5
While those with ketosis-prone diabetes have features of both type 1 and type 2 diabetes, they’re not diagnosed until they present with unprovoked DKA. Ketosis-prone diabetes is classified according to the presence or absence of autoantibodies and beta-cell function. Following aggressive treatment, beta cell function usually recovers and many patients can discontinue insulin therapy, but over the years, they may cycle between insulin deficiency and remission.
Medication Therapy Management Prevents Recurrent Ketoacidosis
Since diabetic ketoacidosis is a medical emergency, treatment primarily falls to hospital staff, but it’s important to know that patients aren’t out of the woods after they’re discharged. In fact, their health may require intensive outpatient management, given that one in five experiences recurrent episodes, Diabetes Care reported in July 2016.6 A team approach that includes medication therapy management is always beneficial for patients with chronic disease, but it’s life-saving for patients with diabetic ketoacidosis for a few reasons:
- Fragmented health care: The study in Diabetes Care found that 16 percent of patients with recurrent DKA were treated at more than one hospital. This fragmented care doubled their odds of recurrent episodes. A brown bag medication review is one of the best tools for monitoring patients’ overall care.
- Risk of death: The risk of death increases with each episode of DKA, whether the patient has type 1 or type 2 diabetes. The data reviewed in Diabetes Care noted that about 14 percent of patients died over six years. Another study from a group at Edinburgh Centre for Endocrinology and Diabetes reported that a single episode of DKA was associated with a 5 percent risk of death within four years following discharge. By comparison, 23 percent of patients with recurrent DKA died within two years.7
- Adherence to treatment regimen: Prevention of DKA depends on rigorous compliance with the treatment plan; adherence improves when pharmacists are on the outpatient health care team.
Tips for Pharmacist Outreach to Optimize MTM
Now that the Centers for Medicare and Medicaid Services (CMS) rate hospitals, physicians and insurance providers on quality, performance, and patient outcomes, pharmacists must also track quality metrics. Two of the quality measures that affect CMS Five-Star Quality Ratings—patient adherence to diabetes medications and MTM—are directly related to your efforts. Here are a few tips for helping patients prevent DKA while raising your star ratings:
- Monitor SGLT2 inhibitors: When SGLT2 inhibitors cause DKA in patients with type 2 diabetes, their blood glucose is either normal or only slightly elevated, which delays diagnosis. Advise these patients to get immediate medical attention if they have symptoms like vomiting, nausea, shortness of breath, abdominal pain, or confusion.8
- Counsel newly diagnosed patients: Even though physicians screen for DKA at the time of diagnosis, pharmacists should be sure to alert patients to the symptoms and the serious nature of DKA when they fill their first prescription.
- Talk about barriers to medication adherence: Be up front about the issues most likely to affect adherence, such as drug costs, insurance coverage, complex regimens, and adverse effects. Reduce costs by recommending generics, simplify the regimen with combination drugs or once-daily formulations, and recommend switching to medications that eliminate side effects. Don’t forget that patients may not understand the importance of taking their medications.9
- Reach out to physicians: The trend toward forming outpatient health care teams is gaining momentum because a coordinated team makes a significant difference in the long-term health of patients with diabetes. It may be up to you to take the first step to form a collaborative drug therapy management team. When you’re part of a formal team, you should be able to bill for your services, either directly to Medicare part D or by using the physician’s provider number.
Make Your Pharmacy a Diabetes Destination
One of the best ways to prevent recurrent diabetic ketoacidosis is to make your pharmacy the place to go for diabetes care. The backbone of such a niche is a section in the pharmacy dedicated to diabetes, but don’t set it up once and leave it static—make a plan to highlight new products or new information about self-care every month. Go beyond basic diabetic supplies to provide educational resources and nutritional supplements. You may even want to become a certified diabetes educator. If not, host regular sessions with a local diabetes educator, even if it’s just an open forum for patients to come and ask questions. It takes all of these efforts—and a community health care team—to promote optimal health in patients with diabetes.
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- “Diabetic Ketoacidosis in Type 2 Diabetics: A Novel Presentation of Pancreatic Adenocarcinoma,” April 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842543/ ↩
- “Ketoacidosis Occurs in Both Type 2 and Type 2 Diabetes – a Population-Based Study from Northern Sweden,” July 2008, http://www.ncbi.nlm.nih.gov/pubmed/18644074 ↩
- “Prevalence of Diabetic Ketoacidosis at Diagnosis,” April 2014, http://www.diabetesincontrol.com/prevalence-of-diabetic-ketoacidosis-at-diagnosis/ ↩
- “Diabetic Ketoacidosis,” July 2016, http://emedicine.medscape.com/article/118361-overview#a5 ↩
- “Approach to the Patient with Atypical Diabetes,” June 2014, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049991/ ↩
- “An Evaluation of Recurrent Diabetic Ketoacidosis, Fragmentation of Care, and Mortality Across Chicago,” July 2016, http://care.diabetesjournals.org/content/early/2016/07/13/dc16-0668 ↩
- “Risk of Death Following Admission to a UK Hospital with Diabetic Ketoacidosis,” July 2016, http://link.springer.com/article/10.1007%2Fs00125-016-4034-0 ↩
- “Understanding SGLT2 Inhibitors’ Diabetic Ketoacidosis Risk,” August 2016, http://www.pharmacytimes.com/contributor/deepali-dixit-pharmd-bcps/2016/08/understanding-sglt2-inhibitors-diabetic-ketoacidosis-risk ↩
- “Medication Therapy Management Challenges in Patients With Diabetes: A Systematic Review,” October 2015, https://www.uspharmacist.com/article/medication-therapy-management-challenges-in-patients-with-diabetes-a-systematic-review ↩