Increased Risk of Hyperglycemic Crises in Diabetes Linked To Age, Race, and Income


Investigators noted a need for multidisciplinary interventions for prevention of diabetic ketoacidosis and hyperglycemic hyperosmolar state in patients with diabetes.

Rozalina G. McCoy, MD

Rozalina G. McCoy, MD

Although diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are associated with life-threatening emergencies in patients with diabetes, there is limited data on patient-level risk factors, making it difficult to reduce frequency of these events at a larger, population level.

New research investigated sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adult patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) in the US.

A team of investigators, led by Rozalina G. McCoy, MD, Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, found factors that increased risk of hyperglycemic crises included younger age, Black race/ethnicity, low income, and poor glycemic control, noting the need for multidisciplinary interventions for prevention of DKA and HHS.


A retrospective cohort study design used medical and pharmacy claims data for adults (≥18 years) with T1D or T2D included in the OptumLabs Data Warehouse (OLDW).

The team identified individuals with diabetes through available HbA1c data between January 2014 - December 2019.

Primary outcomes for the study included rates of emergency department (ED) visits or hospitalization with a primary diagnosis of DKA or HHS between the study dates.

Data on patient age, sex, race/ethnicity, annual household income, and US census region of residence was identified from enrollment files.

Investigators determined glucose-lowering therapy based on prescriptions filled during ≥120 before the index date. In patients with T1D, the study assessed whether they had prescriptions filled for non insulin medication, prescriptions for insulin without non insulin medication, or no prescriptions.

The study assessed the association of sociodemographic factors, clinical factors, including comorbidities, and treatment factors with DKA or HHS in patients with T1D or T2D using negative binomial regression.


A total of 20,156 patients with T1D and 796,382 patients with T2D were included in the study, with the mean duration of 2.4 years and 2.6 years for each cohort, respectively.

Further, a total of 1273 patients with T1D (6.3%) experienced 2397 episodes of hyperglycemic crises, while 5795 patients with T2D (0.7%) experienced 8005 hyperglycemic crises.

Data show the adjusted rates of hyperglycemic crises were 52.69 events per 1000 person-years (95% CI, 48.26 - 57.12 per 1000 person-years) for patients with T1D.

In patients with T2D, the adjusted rate of hyperglycemic crises were 4.04 per 1000 person-years (95% CI, 3.88 - 4.21 per 1000 person-years).

For both patient groups, factors associated with increased risk of hyperglycemic crises included Black race/ethnicity (T1D incidence risk ratio (IRR), 1.33 (95% CI, 1.01 - 1.74); T2D IRR, 1.18; 95% CI, 1.09 - 1.27) and lower annual household income (≥$200,000 versus $40,000: T1D IRR, 0.61; 95% CI, 0.46 - 0.81; T2D IRR, 0.69; 95% CI, 0.58 - 0.86).

In addition, data show increased risk of hyperglycemic crises with high HbA1c level (≥10% versus 6.5% - 6.9%: T1D IRR, 7.81; 95% CI, 5.78 - 10.54; T2D IRR, 7.06, 95% CI, 6.26 - 7.96) and history of hyperglycemic crises (T1D IRR, 7.88; 95% CI, 6.06 - 9.99; T2D IRR, 17.51, 95% CI, 15.07 - 20.34).

Data show age had a U-shape association with hyperglycemic risk in patients with T1D, in comparison to patients aged 18 - 44 years (45 - 64 years IRR, 0.72, 95% CI, 0.59 - 0.87; 65 - 74 years IRR, 0.62, 95% CI, 0.47- 0.80; ≥75 years IRR, 0.96, 95% CI, 0.66 - 1.38).

Further, the risk of hyperglycemic crises decreased progressively with age in patients with T2D (45 - 64 years IRR, 0.57, 95% CI, 0.51 - 0.63; 65 - 74 years, IRR, 0.44, 95% CI, 0.39 - 0.49; ≥75 years IRR, 0.41, 95% CI, 0.36 - 0.47).


Investigators concluded data show efforts are needed to both facilitate engagement of these groups within the healthcare system and address potential barriers to optimal control of blood glucose level.

“Health care delivery systems should incorporate educational, clinical, and social support systems into clinical practice, and payers should consider expanding reimbursement for self-management education and social services as well as more comprehensive coverage for glucose-lowering medications, insulin, and glucose-monitoring technologies,” investigators wrote.

The study, “Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020,” was published online in JAMA Network Open.

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