Diabetic ketoacidosis was more prevalent among racial minorities with type 1 diabetes and COVID-19, researchers reported.
In a cross-sectional study of 180 with type 1 diabetes and lab-confirmed COVID-19 infection, Black and Hispanic patients were significantly more likely to also present with diabetic ketoacidosis than white patients, Osagie Ebekozien, MD, MPH, of the T1D Exchange in Boston, and colleagues wrote in the Journal of Clinical Endocrinology & Metabolism.
While only 13% of white patients with type 1 diabetes and COVID-19 presented with diabetic ketoacidosis, an alarming 33% of Hispanic and 55% of non-Hispanic Black patients did.
This equated to almost a four-times higher odds of Black patients presenting with diabetic ketoacidosis than white patients (adjusted odds ratio 3.7, 95% CI 1.4-10.6).
And after adjustment, Hispanic patients saw about a two-times higher odds of presenting with diabetic ketoacidosis as well (aOR 1.9, 95% CI 0.7-5.7), although this wasn’t statistically significant.
All patients who presented with diabetic ketoacidosis were admitted to the hospital.
Underlying this, Black and Hispanic patients had a significantly median HbA1c than white patients. While white patients had median A1c of 8.3, in Black and Hispanic patients median A1c was 11.7 and 9.7, respectively.
“This is the first major study to examine racial-ethnic inequities for people with type 1 diabetes and COVID-19 that are brought on by structural and systemic racism,” Ebekozien explained in a statement. “We used a diverse cohort of patients with type 1 diabetes and found there is a significantly increased risk of worse outcomes for Black and Hispanic patients with COVID-19 and diabetes.”
“Our findings of troubling and significant inequities call for urgent and targeted interventions, such as culturally appropriate diabetic ketoacidosis awareness campaigns, increased continuous glucose monitoring coverage for minority patients and health care provider participation in a Quality Improvement Collaborative,” he added.
Social determinants of health such as income, education, and racial segregation, compounded by lack of healthcare access, are all reasons behind these health inequalities, the group asserted.
Ebekozien’s group had published another study in November 2020 that found people with type 1 diabetes were more likely to be hospitalized with COVID-19 if they were Black, older, use public insurance, or have hypertension. That analysis also found people who were hospitalized with COVID-19 were less likely to use continuous glucose monitoring or an insulin pump. In this cohort, median HbA1c was 8.6%, which was tied to 42% higher probability of hospitalization than those with lower A1c values.
For the current analysis, the researchers drew upon data from 52 T1D Exchange endocrinology clinical sites in the U.S. A positive COVID-19 test was defined by molecular testing from nasopharyngeal swabs, throat swabs, sputum, or other bodily fluid testing. Diabetic ketoacidosis was defined as presenting with blood glucose over 200 mg/dL, venous pH less than 7.3 or bicarbonate less than 15 mmol/L, ketonemia, and ketonuria.
Among the 180 patients with type 1 diabetes who tested positive, 34% where white, 24% were Black, and 20% were Hispanic.
Similar to the group’s prior study, Black and Hispanic patients were less likely than whites to be using continuous glucose monitoring or an insulin pump. They were also more likely to be female, hold public insurance, and have higher average HbA1c levels than white patients.
One limitation of this study was lack of data on the timing of diabetic ketoacidosis presentation relative to COVID-19 infection.
The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received support for this study from Abbott Diabetes, JDRF, Dexcom, Medtronic, Insulet Corporation, Lilly, and Tandem Diabetes Care.
Ebekozien and co-authors reported no disclosures.