Diabetic Ketoacidosis

June 13, 2013

Treatment for diabetic complication ineffective, new study finds

A commonly used treatment for a serious complication of diabetes made no difference in how much better patients got or how quickly they improved, a study by University Health System pharmacists has found.

And that should make doctors think twice before administering it — even though it’s still included as an optional therapy in professional guidelines for the treatment of diabetic patients, said Bryson Duhon, currently a clinical assistant professor of pharmacy at the University of Texas at Austin, and lead author of the study.

The patients at University Hospital suffered from diabetic ketoacidosis, or DKA. It occurs when the body has to switch to burning fat for energy instead of sugar because of a lack of insulin. When that happens, acidic substances called ketones are formed as a byproduct.

That build-up of ketones can cause nausea and abdominal pain, difficulty breathing and decreased consciousness that can lead to coma. In the United States, the condition is responsible for a half-million hospital days per year, costing an estimated $2.4 billion in direct and indirect costs.

“Not a lot of people die from DKA,” Duhon said. “The big problem with these patients is fluids. Because with severe DKA, when your glucose is very high, the patients urinate a lot to get rid of that glucose and become really dehydrated. Compounded with the acidosis, that sets you up for a bad outcome.”

So the first-line treatment is to give the patient fluids. But along with that, many doctors give an IV solution of sodium bicarbonate — the same compound used in baking soda and over-the-counter antacids — to lower the acidity in the blood more quickly.

Over the years, studies have found a lack of evidence for its use, and professional guidelines published by the American Diabetes Association now recommend it only for severe cases — those with a pH level of 6.9 or lower. Most healthy people have a pH of 7.4.

Duhon, who launched the study while a pharmacy resident at University Hospital, looked back at four years of patient records and found 86 adults with severe DKA — those with a pH of 7.0 or less. There were a few more Type 1 diabetics than Type 2. He believes it is the first study to look exclusively at severe DKA in adults.

All the patients received fluids. In addition, 44 received IV sodium bicarbonate and 42 did not. The study found that both groups were restored to healthy levels after eight hours. And both groups required the same amount of time in the hospital before discharge.

“You never want to give anyone a drug that isn’t doing any good,” Duhon said. “Also, in the past couple of years there have been a lot of drug shortages, with sodium bicarbonate being one of the ones in shortage."

The study was published in the June edition of Annals of Pharmacotherapy. Co-authors were Ana C. Franco, Darrel W. Hughes and Pamela R. Maxwell, all full-time clinical pharmacists at University Hospital’s Inpatient Pharmacy, and adjunct faculty with UT Austin College of Pharmacy; and Rebecca L. Attridge, assistant professor of pharmacy practice at the University of the Incarnate Word, and a PRN pharmacist at the hospital’s Inpatient Pharmacy.