I was involved in an interesting discussion this morning.
An individual I know is being considered for a job at another agency and part of his interview was with the agency’s medical director. Some of the questions he was asked were diabetes-related, and one in particular was whether or not there was any difference in DKA symptoms depending on whether the diabetes is Type I or Type II.
On first glance, treatment would be the same if the patient indeed does have DKA. However, my friend – a rather young but quite competent medic – was asked how DKA is different in Type II diabetes, and he was honest: he wasn’t certain. He told me that the doctor explained to him that Type II diabetics generally don’t have incidence of DKA unless there is a causative event. An example would be an infection of some sort.
I hadn’t really given it a lot of thought. After all, why would treatment be any different? The short answer is that it wouldn’t be; definitive care consists of fluid resuscitation, insulin and glucose, normalization of the body’s pH level, and replacement of depleted electrolytes, especially potassium ions because with the polyuria associated with DKA would have a considerable effect on electrolyte balance.
As I read about this, what the doc who did the interview said was right: the base issue is cause, not treatment. With Type I diabetics, the main causes of DKA are the absolute deficiency of insulin and the added secretion of glucagon. With Type II diabetes, however, there is more to consider: in addition to the glucagon secretion, other things are happening, notably a stressor event (like an infection or some other insult) and the secretion of other hormones including cortisol, catecholamines (epinephrine, norepinephrine), and growth hormone. And the stressor event is key; if there is no problem present, it is likely that there will be no ketones present.
A couple of other things that I found are worth mentioning. First, in the studies I read the presence of obesity is overwhelming. Second, two ethnic groups tend to exemplify this: African-Americans and those of Hispanic descent.
Treatment of the underlying cause, whether an infection or some other issue, is key. This has to be done in addition to correcting the DKA, and it needs to be done aggressively.
It was an eye-opening discussion. And I learned something from it.
Welch, Brian J., MD, and Zib, Ivana, MD, Case Study: Diabetic Ketoacidosis in Type 2 Diabetes: “Look Under The Sheets.” Downloaded from the American Diabetes Association Web Site on 6/30/2010, http://clinical.diabetesjournals.org/content/22/4/198.full
Wittesley, Craig, MD, Case Study: Diabetic Ketoacidosis Complications In Type 2 Diabetes, Clinical Diabetes, Vol. 18 NO 2, Spring 2000. Downloaded on 6/30/2010, http://journal.diabetes.org/clinicaldiabetes/V18N22000/pg88.htm
Newton, CA, Raskin, P, Diabetic Ketoacidosis in Type 1 and Type 2 Diabetes Mellitus: Clinical and Biochemical Differences. Pubmed.gov, 2004. Downloaded 6/30/2010, http://www.ncbi.nlm.nih.gov/pubmed/15451769