Patients with type 1 diabetes presenting with symptoms of diabetic ketoacidosis may instead have ketosis due to cannabis hyperemesis syndrome, and several criteria can help avoid a misdiagnosis, according to data published in Diabetes Care.
Physicians mostly rely on pH and bicarbonate levels to diagnose and classify DKA and make floor vs. ICU admission decisions, Halis Kaan Akturk, MD, assistant professor of medicine and pediatrics at the Barbara Davis Center for Diabetes at the University of Colorado and communications director of the American Diabetes Association, Diabetes Technology Interest Group, and colleagues wrote. In a single-center analysis, the researchers found that relying only on pH and bicarbonate can be misleading with cannabis users with type 1 diabetes.
“Cannabis use has been increasing among people with type 1 diabetes and we observed frequent ED visits with symptoms similar to diabetic ketoacidosis,” Akturk told Healio. “In this study, we wanted to compare the metabolic parameters of cannabis users and nonusers presenting to the ED with symptoms of DKA. We considered any patients with a positive urine drug screen for cannabis as a cannabis user, and those with a negative urine drug screen as nonusers.”
Akturk and colleagues analyzed electronic medical records data from 68 patients with type 1 diabetes followed at the Barbara Davis Center for Diabetes who were seen in the ED with a DKA diagnosis between January 2016 and January 2021 (172 DKA events). Researchers compared mean levels of venous pH, serum bicarbonate, anion gap and beta-hydroxybutyrate between cannabis users and nonusers, using linear mixed models.
Cannabis users had higher pH (mean, 7.42 vs. 7.09) and bicarbonate (mean, 19.2 mmol/L vs. 9.1 mmol/L) compared with nonusers (P < .0001).
The area under the receiver operating characteristic curve for a positive cannabis urine test result predicting cannabis hyperemesis syndrome was 0.9892.
“There were significant differences in metabolic parameters to distinguish between cannabis users and nonusers,” Akturk said. “Non-cannabis users present with high anion gap metabolic acidosis in DKA as expected, but cannabis users present with additional metabolic alkalosis likely due to recurrent vomiting associated with cannabis hyperemesis syndrome.”
The researchers suggested diagnostic criteria for what they termed “hyperglycemic ketosis due to cannabis hyperemesis syndrome,” or HK-CHS. In addition to high venous blood glucose, high anion gap and high beta-hydroxybutyrate levels, other criteria would include a pH of at least 7.4 and bicarbonate of at least 15 mmol/L in presence of ketosis in patients presenting with symptoms of DKA.
“For patients with type 1 diabetes presenting with symptoms of DKA and an unusual metabolic profile, such as an unexpectedly high pH and high bicarbonate that shows alkalosis, cannabis use should be considered,” Akturk said. “Most hospitals classify and place patients with diabetic ketoacidosis based on their pH and bicarbonate levels based on American Diabetes Association classification criteria, so cannabis users presenting with type 1 diabetes may be misclassified based on current classification system.”
The researchers suggest screening urine toxicology for cannabis in adults with type 1 diabetes who present to the ED with a blood glucose of at least 250 mg/dL, beta-hydroxybutyrate of at least 0.6 mmol/L and a pH of at least 7.4 with bicarbonate of at least 15 mmol/L.
“This cutoff would predict 98% of HK-CHS events,” Akturk said.
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