November 24, 2004
Hyperglycemia and DKA
Question from Cordova, Tennessee, USA:
My daughter has had type 1 for 17 years. She has been diagnosed with gastroparesis, which, currently, seems to be under control. The problem is she goes into DKA very often. So far this year, she has been in the hospital eight times. When she has her period, she is guaranteed DKA. She takes her birth control pills for 90 days straight so she does not have a period every month. It seems that no matter what she does, she cannot stay out of DKA. She “threatens it almost DAILY.”
She has been in the hospital twice in the last three weeks. Her sugars always run high. Almost daily she has a sugar greater than 500 mg/dl [27.8 mmol/L]. For example, today her reading were, 120 mg/dl [6.7 mmol/L] at 3 a.m.; 283 mg/dl [15.7 mmol/L] at 8 a.m. when she took 80 units of Lantus and 11 units of Humalog; 10 units of Humalog for a sausage and biscuit at 10 a.m.; and over 500 mg/dl [27.8 mmol/L] at 11:30 a.m. with large ketones when she took 40 units of Humalog. All of this was before noon. It finally got down to around 268 mg/dl [14.9 mmol/L]
I am desperate. She does not like the pump and goes into DKA quicker. Her doctors are great at getting her out of DKA, but how do we prevent it? She has ALWAYS been hard to control and her endocrinologist says she is “extraordinarily brittle.”
Answer:
The most common cause for recurrent DKA is omitted insulin. Usually, this occurs in somebody who has major psychosocial problems, trouble accepting the restrictions of life with diabetes, major family problems but, occasionally also happens when insulin cannot be provided subcutaneously, only intravenously. Rarely, there are other endocrine or other conditions that co-exist with diabetes and when these are treated the recurrent DKA stops.
The key question is why can the doctors treat the DKA so rapidly but it cannot be prevented and this, too, suggests that insulin doses are being omitted. If a parent or other relative actually draws up and administers all the insulin doses, this diagnosis is then confirmed and the problem of the recurrent DKA ceases. Sometimes such psychological problems are associated with eating disorders, sexual or physical abuse that have not been acknowledged or talked about. Sometimes, it is just a severe type of depression.
You should return to your diabetes team and ask these questions directly to them so that they can provide you the best individualized answer for your situation. And, they should also give you specific suggestions about how such recurrent DKA should be prevented.
SB
