key: cord-318038-psultpzy
authors: José Concepción Zavaleta, Marcio; David Armas Flórez, Cristian; Alberto Plasencia Dueñas, Esteban; Cristina Coronado Arroyo, Julia
title: Diabetic ketoacidosis during COVID-19 pandemic in a developing country
date: 2020-08-25
journal: Diabetes Res Clin Pract
DOI: 10.1016/j.diabres.2020.108391
sha: 
doc_id: 318038
cord_uid: psultpzy

nan

We read with interest the study published by Goldman et al [1] , who identified four patients with diabetic ketoacidosis (DKA) resistant to standard therapy that was triggered by COVID-19 and was associated with high morbidity and mortality. This is also happening in developing countries such as Peru, which has the highest number of COVID-19 cases per million inhabitants and the second-lowest public healthcare spending according to WHO [2] .

In our Endocrinology inpatient department at a social security hospital in Peru, from the beginning of the pandemic to date, we have treated 14 patients with DKA who were transferred from the emergency service after they had met the resolution criteria. Of these patients, nine presented with new-onset diabetes. Four tested positive for SARS-CoV-2, three by RT-PCR and one by ELISA, and two patients died. In total, six, six, and two patients had severe, moderate, and mild DKA, respectively. Nine developed acute kidney injury, and six developed acute pancreatitis. Table 1 .

The mechanism by which SARS-CoV-2 triggers DKA has not been fully elucidated; however, it has been shown that it uses the receptor for angiotensin-converting enzyme 2 as a gateway, which is expressed in the intestine, kidney, and pancreas [3] , organs that are part of the "egregious eleven," the pathophysiological basis of type 2 diabetes mellitus [4] . Accordingly, the virus can cause cellular destruction of the islets of Langerhans, which may explain the higher incidence of DKA [3] in patients with and without known diabetes. This damage can be expressed by an elevation of pancreatic enzyme levels in patients with COVID-19 [5] ; however, DKA itself can present with elevated pancreatic enzyme levels in 16%-25% of cases [6] . Likewise, a state of insulin resistance triggered by COVID-19 has been described, which, together with pancreatic injury, contributes to an increased risk of hyperglycemic crisis in patients with diabetes [3] .

In our experience, an insulin infusion pump was continuously used to manage patients with mild and moderate DKA. Hence, healthcare workers were highly exposed to patients with COVID-19. However, the American Diabetes Association and the Joint British Diabetes Societies have recommended the administration of rapid subcutaneous insulin every 4 hours [7] . This regimen is safe and effective. Furthermore, it minimizes the time spent for bedside care and conserves the use of personal protective equipment [8] , which should be prioritized in our country considering the shortage of equipment, supplies, and medicines needed for COVID-19.

The authors declare no conflict of interest in this publication

The authors received no funding from an external source

High prevalence of COVID-19-associated diabetic ketoacidosis in UK secondary care

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Guidance on the management of Diabetic Ketoacidosis in the exceptional circumstances of the COVID-19 pandemic