Which results in more hospitalisations: severe hypos or severe hypers (DKA)?

[smidge]

Hi everyone!

I've been pondering which is the more dangerous condition, severe hypo or severe hyper (DKA) and I can't seem to find any evidence to suggest one or the other.

We all know that high BG causes serious complications over a period of years but those of us on insulin tend to be more scared of the immediate danger of hypos. And yet, I think I've read at least as many reports of insulin-dependents being hospitalised through very high BG and a lack of insulin causing DKA as being hospitalised through serious hypos.

So what is the truth? Which of the two conditions results in more hospitalisations each year and which causes the most deaths? Does anyone have any statistics on this? What are your thoughts? Which condition worries you the most?

Smidge

 

[Scandichic]

Both of them are lethal so both don't have any facts I'm afraid!

 

[Spiker]

Mortality on both is of the order of single digit percentages per incident. Which is pretty terrifying. I must be beating the odds on severe hypos, and I don't like to think about that too much.

Are you asking about what's more frequent in a diabetic's life or what's more prevalent from the NHS's point of view? Just in case they're not the same thing. In my life severe hypos massively outnumber DKA, though from a hospital admission point of view it's probably "only" about 3:1 of severe hypo hospitalisations over DKA hospitalisations. But who's counting.

It's hard to say which is the worse experience subjectively. They are both absolutely horrible.

 

[David Gray]

I was wondering exactly the same. I err on the low side as, like you say, highs tend to create more complications. My Grandfather had type 1, and was forever falling into a coma, as i remember when i was a child, they would always wait for him to come round and give him a cup of sweet tea and he always seemed oblivious to having passed out ! He lived to 76 without any complications. Was he just lucky? What do others think?

 

[mo1905]

My guess would be hypo's are much more common but DKA would require more hospital admissions ( not hypers, very different ). No evidence, just my opinion.

 

[paul-1976]

A hypo although potentially very dangerous or fatal in certain circumstances is quicker to treat under normal circumstances whereas DKA can involve intensive therapy as an inpatient for many days although both ends of the spectrum can be deadly.
Don't fancy either scenarios to be honest.

 

[noblehead]

So what is the truth? Which of the two conditions results in more hospitalisations each year and which causes the most deaths? Does anyone have any statistics on this? What are your thoughts? Which condition worries you the most?

Can't say with any certainty but I would imagine they'd be more cases of hospitalisations from DKA than hypo's. The reason being is the paramedics would encourage someone to eat glucose if they are found having a hypo or would administer the glucagon injection pen if they were unable to eat, having watched programmes like C5's Emergency Bikers they often sit with the patient until such times that they recover rather than take them to hospital, with DKA there no alternative but to be admitted.

As to what worries me more, I would have to say on a daily basis it would be hypo's, I've fortunate to never have had DKA but the thought of it does send a shiver down my spine.

 

[Spiker]

Every time I've had a severe hypo the paramedics have insisted on taking me to hospital for "observation" etc. There was one occasion only where my other half managed to talk them out of it, but that took a lot of persuading and was definitely against their standard procedures.

Unfortunately this is a rather large sample size in my case.

 

[Spiker]

I've actually seen the stats on both of these very recently - severe hypo incidence and DKA incidence, per patient per year. I must have a rummage round and see if I can find them again.

 

[phoenix]

I suspect that DKA causes more hospitalisations, as Nigel says many people with serious hypos are treated at home by paramedics or at most people people are checked over in emergency departments. I have read of a very few cases on forums of people who have had extended comas and required hospitalisations including one person who ended up needing full time care. With older people hypos can be particularly serious in those who already have other serious conditions so may involve longer term care.
For DKA there is normally a necessity for some time in hospital, many people are first diagnosed with DKA which would account for many of the hospitalisations. It also probably causes more deaths in hospitals. ( even more deadly is hypersosmolar non ketotic hyperglycaemia which tends to occur in the elderly)
But both are deadly. The JDFR caused a stir with an advert suggesting that 1 in 20 people with T1 would die from low blood sugar.http://www.huffingtonpost.com/riva-greenberg/jdrf-diabetes-ad_b_1083606.html
An analysis of all Norwegian T1s diagnosed between 1973 and 1982 (aged 15 and below) with deaths recorded as of 2002 found that 103/1906 had died.13% were from DKA, 10% from hypoglycaemia.http://link.springer.com/article/10.1007/s00125-005-0082-6/fulltext.html

 

[Spiker]

Thanks phoenix!

I think it's very certain that DKA hospitalisations will be of longer duration than severe hypo hospitalisations. You are talking a few days vs a few hours. So on that basis, if the frequency is similar (if the death data can be used as a proxy??) then probably more hospital time is used up by DKA than by severe hypos.

 

[Miss90]

They are both dangerous but in my opinion DKA Is worse. I had a severe night time hypo (fitting, unconscious for 20 mins) and the paramedics took me in and then sent me home 3 hours later. They told me that if I had been alone, most likely my liver would have produced glucose and woken me up. 3 weeks later I spent 3 nights in hospital with DKA and felt like hell. Took 24 hours to get my ketones down to a normal level but still felt pretty rough after. For me, DKA was a lot worse as I was vomiting every 5 minutes for 6 hours - yuck!


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[smidge]

I know it all sounds a little morbid, but what got me thinking about it is that I have a cold and my BG has been really erratic. Yesterday, it ranged from 14 something down to 3.2. Anyway, I corrected a 12 something two hours after tea last night and thought maybe I shouldn't have done that because I wanted to go to bed and was worried I'd hypo overnight. But I was also worried that if I hadn't corrected the 12 something, it might rise really badly overnight as it had been rising badly all day.

This got me thinking that in my job I spend a lot of time looking at risk in terms of how likely a risk is to occur versus the impact the risk would have if it did occur and deciding which to accept, which to mitigate etc. I generally have reasonable data to work with in my job. However, it occured to me that I was doing more or less the same thing with my hypo/hyper risk last night but without any reliable data. Basically, I was guessing rather than assessing. So, I thought, consultants etc give us their advice and presumably base that advice on assessment of risk - so what data do they use in their risk assessment and hence in their advice?

Really interesting to see the responses here and read through the articles provided by Phoenix. Given how worried we all are about hypos in particular, I'm surprised that there seems to be so little evidence in the public domain that helps us understand these risks a little better. I want to be able to base my decisions on sound evidence rather than fear really, but as Brian points out (above), even the statistics we do have are an order of magnitude difference in outcome. Although the thing that struck me from the American Ad was the phrase 'kids and adults are dying every day from low blood sugar OR COMPLICATIONS CAUSED BY TYPE 1 DIABETES' - the latter part of that sentence indicating they are including all the deaths from complications of high BG into their stats as well as the hypos - so actually, no help in trying to assess the relative risks. And the European article is also from many years ago when the insulins were not as good and testing kits not as readily available. Surely there is more up-to-date data available to us in such a fundamental area of diabetic life? I would have expected stats on number of deaths from hypo, number of deaths from DKA, number of hospitalisations from hypo and number of hospitalisations from DKA to be the most basic monitoring output in dealing with diabetes.

Smidge

 

[phoenix]

You might be able to find newer stats it would take some time searching for them though. Here's some ten year old English data

In 2004–5, in England, there were just around 8000 hospital admissions related to hypoglycaemia, most of which were due to insulin treatment of type 1 or 2 diabetes mellitus, although sulphonylurea drugs can also cause hypoglycaemic episodes.43 However, most hypoglycaemia episodes are managed by patients and by the ambulance services, and account for about 90

000 callouts per year in the UK

With improved care and early detection, DKA or HHS can be entirely prevented. However, this is not reflected in the hospital admissions in England, with just >7700 admissions in 1998–9 and just <8400 admissions in 2004–5 for admissions with DKA and around 2000 admissions for HHS.4 The EURODIAB study reported an incidence of DKA in type 1 diabetes of 8.6%.5 The mortality from DKA remains low at <5%, but it is the most common cause of death in young people with diabetes and is high in those >65 years of age.6,7,8 For HHS the mortality remains high at around 15% and is even higher in the older population

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805944/

I think it's actually quite difficult to look at risks and be objective about ourselves. That's probably why we see things differently to our doctors
I'd probably give a correction dose and then like you get a bit worried and (benefit of a pump) reduce my basal for the next few hours!

 

[catherinecherub]

I think the massive cost in treating diabetes complications, including hypos and DKA, is starting to hit home if this document is anything to go by.

It sets out improvements that could be made to lessen the financial impact. Most of them are educational for all people involved in diabetic care and for diabetics.
1 in 6 hospital beds in England are occupied by someone with diabetes and health economic analysis suggests that diabetes in England alone account for 670,581 excess day beds, compared to equivalent population without diabetes, at a total estimated tariff expenditure of £573 million in 1 year.

Admission Avoidance in Diabetes.
Guidance for Clinical Commissioning Groups and Clinical Teams. December 2013.

http://www.diabetes.org.uk/Documents/Position statements/admissions-avoidance-diabetes-0114.pdf

Pages 35 - 40 deal with Hypos and D,K.A.

 

[smidge]

I think the massive cost in treating diabetes complications, including hypos and DKA, is starting to hit home if this document is anything to go by.

It sets out improvements that could be made to lessen the financial impact. Most of them are educational for all people involved in diabetic care and for diabetics.
1 in 6 hospital beds in England are occupied by someone with diabetes and health economic analysis suggests that diabetes in England alone account for 670,581 excess day beds, compared to equivalent population without diabetes, at a total estimated tariff expenditure of £573 million in 1 year.

Admission Avoidance in Diabetes.
Guidance for Clinical Commissioning Groups and Clinical Teams. December 2013.

http://www.diabetes.org.uk/Documents/Position statements/admissions-avoidance-diabetes-0114.pdf

Pages 35 - 40 deal with Hypos and D,K.A.

Wow! That's amazing data. I've only skimmed it at the moment, but i'll read it properly later.

Smidge

 

[equipoise]

If 1 in 6 hospital beds in England are occupied by someone with diabetes, it does make it all the more scandalous that hospital food is so diabetic-unfriendly.

 

[mo1905]

1 in 6 seems incredibly high. I guess they may not all be there for diabetes related issues ? If a diabetic was in hospital for a different problem, broken leg for example, would that count as 1 of the 6 ?


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[Jaylee]

This is an interesting thread. Thanks for starting this topic off Smidge..
Personally my fears are the highs as opposed to the lows..

But then i have only ever been hospitalised once, & that was during diagnosis.

 

[tomvonc]

I've had DKA twice in my 3 months as a professional diabetic, both times required a week of hospitalisation. Only had one hypo that needed an ambulance. Paramedics tried to persude me to go to hospital, but I didn't after they made me sign something to discharge their responsibilties I assume.

Tom