Diabetic ketoacidosis prevention

NIDDM is a much more common disease than IDDM, accounting for about 85—90% of all cases of diabetes meUitus. Whereas NIDDM may be present at any age, the incidence increases dramatically with advanced age over 10% of the population reaching 70 years of age has NIDDM. Patients with NIDDM do not require insulin treatment to maintain life or prevent the spontaneous occurrence of diabetic ketoacidosis. Therefore, NIDDM is frequendy asymptomatic and unrecognized, and diagnosis requires screening for elevations in blood or urinary sugar. Most forms of NIDDM are associated with a family history of the disease, and NIDDM is commonly associated with and exacerbated by obesity. The causes of NIDDM are not well understood and there may be many molecular defects which lead to NIDDM. 

A 56-year-old man was given a continuous subcutaneous insulin infusion because of frequent episodes of hypoglycemia of which he was unaware and he had four separate episodes of profound ketoacidosis (194). Multiple daily injections produced less flexibility in his mealtimes, more episodes of hypoglycemia, and the need for more injections. However, injecting 60% of his basal needs as insulin glargine once daily in combination with continuous subcutaneous infusion prevented further episodes of diabetic ketoacidosis. 

Phillips BD, Aurand LA, Bedwell MM, Levy JR. A novel approach to preventing diabetic ketoacidosis in a patient treated with an insulin pump. Diabetes Care 2003 26 2960-1. 

Alcohol taken in excess tends to prevent gluconeogenesis from lactate in the liver, because oxidation of ethanol to acetaldehyde competes for the NAD" that is necessary for the conversion of lactate to pyruvate. Severe acidosis, such as diabetic ketoacidosis, may suppress lactate conversion and cause a shift in the lactate-pyruvate equilibrium with the accumulation of H. This shift may, in part, be responsible for the lactic acidosis seen in diabetics. 

The goals of therapy are the reversal of signs and symptoms of hypophosphatemia, normalization of serum phosphorus concentrations, and management of underlying conditions. Awareness of the clinical situations in which hypophosphatemia may be anticipated (alcoholism, diabetic ketoacidosis, and parenteral nutrition) is of vital importance in preventing iatrogenic hypophosphatemia. The routine addition of phosphorus in concentrations of 12 to 15 mmol/L to intra-... 

Kaufman FR, Halvorson M. The treatment and prevention of diabetic ketoacidosis in children and adolescents with type 1 diabetes mellitus. Pediatr Ann. 1999 28 576-582. 

Conditions that result in increased production of metabolic acids include lactic acidosis and diabetic ketoacidosis. Lactic acidosis occurs with anaerobic metaboUsm in the presence of severe hypoxemia (i.e., Pao < 36 mm Hg). Any condition that prevents adequate oxygenation resulting in hypoxemia, such as respiratory failure or lung cancer, as well as any condition causing a decrease in perfusion to body tissues, such as heart failure or shock of any form, will result in anaerobic metabolism and lactic acid buildup. In diabetic ketoacidosis, the lack of insulin to move glucose into the cells results in a form of starvation and the production and accumulation of ketoacids (i.e., ketosis) owing to the use of lipids for fuel. 

Treatment of metabolic acidosis is focused on correcting the underlying problem. For example, in lactic acidosis, the correction will center on oxygenation to prevent anaerobic metabolism or fixing other causes of the condition. Similarly, in diabetic ketoacidosis, treatment focuses on correcting the insulin deficit to decrease the burning of fats and production of ketones. 

Misra S, Oliver NS. Utility of Ketone Measurement in the Prevention, Diagnosis and Management of Diabetic Ketoacidosis. Diabet. Med. 2015 32 14-23. http //dx.doi. org/10.1111/dme. 12604. 

Bismuth E, Laffel L (2007) Can we prevent diabetic ketoacidosis in children. Pediatr Diabetes 8(Suppl 6) 24—33... 

Exercise is an essential yet neglected aspect of treatment for type 2 diabetes especially in its early stages where insulin resistance may predominate. Accumulation of at least 30 0 minutes of moderate physical activity on most days of the week is recommended. For type 1 diabetes the emphasis must be on adjusting the therapeutic regimen to allow safe sports participation to prevent precipitation of ketoacidosis or hypoglycaemia. Extra care is required in cases with known complications like proliferative retinopathy, nephropathy, foot ulcers and cardiac or peripheral vascular disease. 

Physical therapists and occupational therapists may help reinforce the importance of patient compliance during pharmacologic management of diabetes mellitus. Therapists can question whether patients have been taking their medications on a routine basis. Regular administration of insulin is essential in preventing a metabolic shift toward ketone body production and subsequent ketoacidosis, especially in patients with type 1 diabetes. In addition, therapists can help explain that adequate control of blood glucose not only prevents acute metabolic problems but also seems to decrease the incidence of the neurovascular complications. 

Dietary phtxsphate deficiency is relatively rare because the phosphate content in plant and animal foods is well above the requirement and b ause of the efficient absorption of phosphate (50-90%). Phosphate deficiency can occur in a number of situations. It can occur with the chronic intake of aluminum-based antacids, particularly with a low-phosphate diet. These antacids form a complex with dietary phosphate, preventing its absorption and resulting in the deficiency. Deficiency can occur with increased urinary excretion of phosphate that occurs w ith starvation and in diabetics experiencing ketoacidosis. Chronic alcoholics may be phosphate deficient because of decreased dietary intake, impaired absorption, and increased urinary excretion (Berner and Shike, Phosphate defi-... 

Type II diabetes (NIDDM) is a milder form of diabetes that occurs primarily in adults and accounts for the vast majority of diabetics (ca. 90%). The P cells, though still functioning, respond inadequately to glucose stimulation. The insulin levels are low, but they are usually adequate to prevent the dreaded ketoacidosis syndrome. There is also tissue resistance to insulin. 

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