Type 2 Is Not Immune to Diabetic Ketoacidosis

A significant portion of diabetic ketoacidosis (DKA) cases occur in patients with type 2 diabetes. There are subtle differences from DKA in patients with type I diabetes, but the treatment is the same.
"An episode of DKA was once considered a hallmark feature that would differentiate individuals with type 1 diabetes mellitus from those with type 2 diabetes mellitus," write Christopher A. Newton, MD, and Philip Raskin, MD, from the University of Texas Southwestern Medical Center at Dallas. "With the changes in the frequency of DKA and the increased incidence of DKA in patients with type 2 diabetes mellitus, the question may be posed of whether there has been any change in the clinical or laboratory characteristics of the patients with DKA who present to the emergency department."

The investigators reviewed 176 admissions to the University Diabetes Treatment Center at Parkland Memorial Hospital in Dallas for moderate to severe DKA, including 35 admissions (19.9%) for newly diagnosed diabetes. Of 138 patients admitted for moderate to severe DKA, 30 had type 2 diabetes, based on treatment history and/or autoantibody status. Noncompliance with medication use was involved in 85% of all admissions, including 69.2% in the type 2 diabetes group.

Compared with type 1 diabetes patients, type 2 diabetes patients with DKA were more likely to be Latino American or African American (P <.001), to have infections (48.4% vs. 21.6%), and to have a body mass index greater than 27 (70% vs. 21%). Patients with type 2 diabetes had a different biochemical presentation of DKA, with less severe acidosis (mean arterial pH, 7.27 ± 0.08 vs. 7.21 ± 0.12 (P < .001) and a tendency for normal initial serum potassium levels compared with patients with classic autoimmune type 1 diabetes.

Although the type 1 diabetes group was more acidotic, the type 2 diabetes group required longer treatment to achieve ketone-free urine (36.0 ± 11.6 vs. 28.9 ± 8.9 hours; P = .01). Treatment complications were uncommon.

"Patients with type 2 diabetes can develop more than mild ketosis and may experience moderate-to-severe DKA," the authors write. "The time-tested therapy for DKA of intravenous insulin with concomitant glucose as the plasma level decreases, sufficient fluid and electrolyte replacement, and attention to associated problems remains the standard of care, irrespective of the type of diabetes."

Arch Intern Med. 2004;164:1925-1931

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