Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state.
BACKGROUND
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) cause major morbidity and significant mortality in patients with diabetes mellitus. For more than 30 yr, our group, in a series of prospective, randomized clinical studies, has investigated the pathogenesis and evolving strategies of the treatment of hyperglycemic crises. This paper summarizes the results of these prospective studies on the management and pathophysiology of DKA.


METHODS
Our earliest studies evaluated the comparative efficacy of low-dose vs. pharmacological amounts of insulin and the use of low-dose therapy by various routes in adults and later in children. Subsequent studies evaluated phosphate and bicarbonate therapy, lipid metabolism, ketosis-prone type 2 patients, and use of rapid-acting insulin analogs as well as leptin status, cardiac risk factors, proinflammatory cytokines, and the mechanism of activation of T lymphocytes in hyperglycemic crises.


RESULTS
The information garnered from these studies resulted in the creation of the 2001 American Diabetes Association (ADA) technical review on DKA and HHS as well as the ADA Position and Consensus Paper on the therapy for hyperglycemic crises.


CONCLUSIONS
Areas of future research include prospective randomized studies to do the following: 1) establish the efficacy of bicarbonate therapy in DKA for a pH less than 6.9; 2) establish the need for a bolus insulin dose in the initial therapy of DKA; 3) determine the pathophysiological mechanisms for the absence of ketosis in HHS; 4) investigate the reasons for elevated proinflammatory cytokines and cardiovascular risk factors; and 5) evaluate the efficacy and cost benefit of using sc regular insulin vs. more expensive insulin analogs on the general ward for the treatment of DKA.
Kitabchi
Abbas E
AE
Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, 920 Madison Avenue #909, Memphis, TN 38163, USA. akitabchi@utmem.edu
Umpierrez
Guillermo E
GE
Fisher
Joseph N
JN
Murphy
Mary Beth
MB
Stentz
Frankie B
FB
D001639:Bicarbonates / Q000627:therapeutic use; D016883:Diabetic Ketoacidosis / Q000188:drug therapy*; D006801:Humans; D006944:Hyperglycemic Hyperosmolar Nonketotic Coma / Q000188:drug therapy*; D007328:Insulin / Q000008:administration & dosage* / Q000378:metabolism; D020738:Leptin / Q000097:blood; D050356:Lipid Metabolism; D008213:Lymphocyte Activation; D010710:Phosphates / Q000627:therapeutic use; D013601:T-Lymphocytes / Q000276:immunology
D001639:Bicarbonates; D007328:Insulin; D020738:Leptin; D010710:Phosphates