Researchers analyzed 6,242 individuals from the 2016-2017 Type 1 Diabetes Exchange Clinical Registry and found that
9.5% of those with HbA1C levels in the range of DCCT 9% or more experienced a diabetic ketoacidosis episode,
compared with
1.7% of those with levels between the range of DCCT 7% or 52 mmol/mol
The findings, presented at the American Association of Clinical Endocrinologists annual meeting, also revealed that the use of daily insulin injections among those whose A1C levels were in the 9% or more range was tied to a significantly higher DKA risk than insulin pump users.

Adults with type 1 diabetes and HbA1c levels of at least 9% are more likely to develop diabetic ketoacidosis, or DKA, than those who reach lower targets, according to findings presented at AACE Annual Scientific and Clinical Congress.

“Achieving glycemic control remains a major barrier to the health and well-being of patients with type 1 diabetes. In addition to the known long-term vascular complications of hyperglycemia, patients with the poorest glycemic control are also at the highest risk for DKA,” Carol H. Wysham, MD, FACE, FACP, Endocrine Today Editorial Board member and clinical professor of medicine at the University of Washington Rockwood Clinic/MultiCare Health System in Seattle, told Endocrine Today. “Health care providers should continue to monitor and educate all patients on the risk factors associated with developing DKA, and be vigilant in patients with HbA1c greater than 9%.”

Wysham and colleagues conducted a cross-sectional analysis of 6,242 participants in the 2016-2017 Type 1 Diabetes Exchange Clinical Registry.

Episodes of diabetic ketoacidosis were identified with questionnaires, and participants were divided into categories based on HbA1c levels of 7% to less than 8%, 8% to less than 9%, and at least 9%. Most participants in the study cohort fell within the 7% to less than 8% range (43%), followed by the 8% to less than 9% range (31%) and the 9% or more range (30%). 

A higher percentage of participants with HbA1c levels in the 9% or more range had an episode of DKA (9.5%) compared with the 7% to less than 8% group (1.7%) and the 8% to less than 9% group (2.3%). According to Wysham, those in the 9% and higher group were five times more likely to have a DKA event than those in the 7% to less than 8% group and four times more likely that those in the 8% to less than 9% group. 

Multivariate-adjusted models revealed associations between DKA incidence and a number of socioeconomic factors, including household income, smoking status and insulin delivery method, according to Wysham, who said that those with HbA1c of 9% or more who used daily injections “had significantly higher risk of DKA than pump users.”

“Ongoing education to our adult patients on recognizing and avoiding DKA is an important part of clinical practice for patients with type 1 diabetes,” Wysham said. “Patients with poor glycemic control, especially those with HbA1c greater than 9%, are at higher risk for developing DKA, and understanding contributing associated factors such as those identified in our work can clinicians gauge those at greatest risk.” – by Phil Neuffer


Wysham C, et al. Incidence and associated risk factors of diabetic ketoacidosis in hyperglycemic adult patients with type 1 diabetes. Presented at: AACE Annual Scientific and Clinical Congress; April 24-28, 2019; Los Angeles.



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