Youth with type 1 diabetes (T1D) who have A1c levels ≥ 9% have a 13-fold higher rate of diabetic ketoacidosis (DKA) than youth with A1c <7.5% and the rate of DKA is 2-fold higher with multiple daily injections (MDI) than with pump therapy. However, the frequency of mild to moderate ketosis (the gateway to DKA in these high-risk patients) is largely unknown and such knowledge is essential to evaluate strategies aimed at DKA prevention.

Methods: Youth ages 8-18 years with uncontrolled T1D (A1c> 8.5%) on MDI treatment were enrolled in the study. Blood glucose (BG) and blood β-hydroxybutyrate (BHB) levels were measured by school personnel in the AM on arrival to school.

Results: 14 patients (age 15 ± 2.3 years) enrolled in the study had A1c 10.7 ± 1.5% (range 8.8 - 14.0%). BHB or urine ketones were measured on 125 school days; ketone levels were small (0.6-0.9 mmol/L) on 6.4% of days (mean BHB 0.7+0.1 mmol/L) and moderate/large (>0.9 mmol/L) on 10.4% of days (mean BHB 2.1+1.4 mmol/L) (Figure). BG ranged between 147 to >600 mg/dL on days with elevated BHB levels; all were without other signs or symptoms of DKA.

Conclusions: Unrecognized mild to moderate ketosis during regular school attendance is common in youth with uncontrolled T1D on MDI therapy. Novel strategies, such as having school personnel supervise injections of long-acting basal insulin, are needed to support reliable insulin dosing to prevent ketosis in youth with uncontrolled T1D at risk for DKA

L.M. Nally: None. S. Elahi: None. M.A. Van Name: Research Support; Self; Novo Nordisk Inc. A. Steffen: None. E.M. Tichy: None. A.D. Urban: None. K. Weyman: None. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited.


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