Diabetic ketoacidosis: not always due to type 1 diabetes
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3501 (Published 10 June 2013) Cite this as: BMJ 2013;346:f3501
- S Misra, specialty registrar metabolic medicine1,
- NS Oliver, consultant diabetologist 2,
- A Dornhorst, consultant diabetologist2
- 1Department of Metabolic Medicine and Clinical Biochemistry, Imperial Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK
- 2Department of Diabetes and Endocrinology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
- Correspondence to: S Misra smisra{at}imperial.ac.uk
- Accepted 14 May 2013
Summary points
Patients presenting with diabetic ketoacidosis may have type 1 or type 2 diabetes
Diabetic ketoacidosis should be treated with insulin in accordance with nationally agreed guidance
After treatment of diabetic ketoacidosis, patients found to have type 2 diabetes may not require lifelong insulin treatment
Consider ketosis prone type 2 diabetes in older, overweight, non-white patients who present with diabetic ketoacidosis at their first presentation of diabetes; this diagnosis is also a possibility in patients with any features that are atypical for type 1 diabetes
Discharge all patients on insulin and arrange for specialist follow-up
Under specialist supervision consider whether insulin can be down-titrated on the basis of clinical progress and, where possible, C peptide and antibody measurements
Who gets diabetic ketoacidosis?
Diabetic ketoacidosis (DKA) is not just the hallmark of absolute insulin deficiency in type 1 diabetes—it is increasingly being seen in people presenting with type 2 diabetes.1 2 This is at odds with traditional physiological teaching—that clinically significant ketosis does not occur in the presence of insulin concentrations associated with type 2 diabetes because there will always be sufficient insulin to suppress lipolysis (fig 1⇓).3 Current knowledge suggests that some people with type 2 diabetes may develop acute reductions in insulin production, which, coupled with insulin resistance, can cause DKA, usually without a precipitant.4 This is particularly so in African-Caribbean and other non-white ethnic groups.5 6 This potentially life threatening presentation of type 2 diabetes is referred to as ketosis prone type 2 diabetes (also Flatbush or type 1b diabetes). Clinicians should be aware of this variant of type 2 diabetes because observational studies in African-Caribbean people presenting with ketoacidosis indicate that 20-50% have type 2 diabetes.2
Fig 1 Physiological effects …
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